Editor's Picks/Most Viewed Pediatric Anesthesia Articles ofthe Day: September 2025
Melissa Brooks Peterson MD and Myron Yaster MD
Original article
Peterson MB, Yaster M. Editor's Picks/Most Viewed Pediatric Anesthesia Articles of the Day: September 2025. Paediatr Anaesth. 2026 Apr;36(4):469-470. doi: 10.1002/pan.70117. Epub 2026 Jan 9. PMID: 41517940.
Today’s editor’s picks for the Pediatric Anesthesia Article of the Day are the articles with the highest “opens” and the most reader responses in the month of September 2025. This is a good opportunity to review these recent PAADs.
Title: Optimal Dose of Intranasal Midazolam.
Link: https://ronlitman.substack.com/p/optimal-dose-of-intranasal-midazolam.
Original article:
Tsze DS, Woodward HA, McLaren SH, Leu CS,Venn AMR, Hu NY, Flores-Sanchez PL, Stefan BR, Shen ST,Ekladios MJ, Cravero JP, Dayan PS. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025 Jul 28. doi: 10.1001/jamape-diatrics.2025.2181. Epub ahead of print. PMID: 40720114.
Summary
In this randomized clinical trial, the optimal doses of intranasal (IN) midazolam for procedural sedation in children undergoing laceration repair were 0.4 and 0.5 mg/kg rather than the most commonly used lower 0.2–0.3 mg/kg. The authors reported no adverse effects (respiratory depression, hypotension, oxygen de-saturation, nausea or vomiting). Finally, there was no mention of nasal mucosa burning, a side effect commonly cited by pediatric anesthesiologists. Not discussed in today’s article is how IN drug delivery works. Our PAAD authors discuss the nuances of how IN medication administration works in detail.
Title: Platelet transfusion: how low before you need to transfuse?
Link: https://ronlitman. subst ack.com/p/platelet-transfusion-how-low-before-d9d.
Original article:
Metcalf RA, Nahirniak S, Guyatt G, Bathla A, et al. Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines. JAMA.2025 May 29. doi: 10.1001/jama.2025.7529. Epub ahead of print.PMID: 40440268.
Summary
Platelet transfusions can be life-saving when needed to manage a hemostatic derangement or life-threatening when given solely to treat an abnormal number. Key consensus guideline recommendations are discussed including: In nonbleeding patients with lymphoproliferative thrombocytopenia actively receiving chemotherapy or undergoing allogeneic stem cell transplant(SCT): Transfuse only if platelets < 10 × 10 3/μL. In patients undergoing lumbar puncture: Transfuse only if < 20 × 10 3/μL, otherwise hold because the risk of spinal hematoma is extremely low. We caution that while expert consensus can guide practice, reduce variability, and prevent over- or unnecessary transfusion, large prospective pediatric and neonatal trials are needed to take into consideration the platelet count and also platelet function, as well as the dynamic and individual hemostatic status of the neonate, infant, child or adolescent.
Title: Error Traps in Infant Spinal Anesthesia (SA).
Link: https://ronlitman.subst ack.com/p/error-traps-in-infant-spinal-anesthesia-078.
Original article:
Froyshteter AB, Lazar A, Holman AE, FrawleyG, Whitaker EE. Error Traps in Infant Spinal Anesthesia Paediatr Anaesth. 2025 Aug;35(8):598–606. doi: 10.1111/pan.15132. Epub 2025 May 30. PMID: 40444570.
Summary
Another in the error trap series published in Pediatric Anesthesia. As way of reminder, “error traps are conditions or situations that make errors more likely to occur. They are not hazards themselves but rather increase the risk of something going wrong. ”Think of them as “error-producing conditions” that can lead to undesirable consequences if not addressed. Errors discussed include (1) Failure to appropriately prepare the infant for SA,(2) “no CSF, no spinal block” is just as true in the infant as itis in adults (3) Use a 22 or 25 gauge, styleted needles (to avoid introduction of epidermal tissue). (4) A good rule of thumb in newborns is that the needle will puncture the dura in mm at (2 ×weight in kg) + 7. (5) Spinal anesthesia lasts about 60–90 min—plan accordingly! (6) Dosing for isobaric bupivacaine 0.5% is1 mg/kg or 0.2 mL/kg, with a maximum dose of 5 mg or 1 mL for infants > 5 kg and a minimum volume of 0.3–0.4 mL.
Title: In patients with a predicted difficult airway: weekendversus weekday presentation increases the risk of trachealintubation-complications.
Link: https://ronlitman. subst ack.com/p/in-patients-with-a-predicted-difficult.
Original article:
Crockett CJ, Szolnoki J, Khan S, Lee AC, Kaizer A, Olomu P, Brooks Peterson M; Pediatric Difficult Intubation Collaborative. Pediatric difficult intubations and the impact of timing of weekend versus weekday cases: an analysis of the Pediatric Difficult Intubation registry. Br J Anaesth. 2025 Aug18:S0007- 0912(25)00447–7. doi: 10.1016/j.bja.2025.07.033. Epub ahead of print. PMID: 40829974.
Summary
In this retrospective study of the pediatric difficult airway registry data, the primary objective was to compare total complication rates when children with difficult airways were cared for on the weekends versus on weekdays. What did they find? “The odds of any complication were more than two times higher on the weekends compared with weekdays (odds ratio 2.13, 95%confidence interval 1.49–3.07, p < 0.0001).” And the authors conclude: “This study supports pediatric anesthetists’ clinical decision-making to postpone nonurgent pediatric procedures in children with a history of a difficult airway from weekend to weekday to decrease risk of airway management complications and improve patient safety and quality of care.”
Title: Sugammadex Anaphylaxis: Mechanisms, Diagnosis, andIncidence.Link: https://ronlitman. subst ack.com/p/sugam madex-anaphylaxis-mechanisms.
Original article:
Savic, Louise M.B., B.S.1; Silversides, JonathanA. M.B., B.Ch., B.A.O.(Hon), Ph.D.2; Leslie, Kate M.B.B.S.,M.Epid., M.Hlth.Serv.Mt., M.D., Hon.D.Med.Sci.3. SugammadexAnaphylaxis: Mechanisms, Diagnosis, and Incidence.Anesthesiology. 2025 July; 143(1):199–204. doi: 10.1097/ALN.0000000000005431.
Summary
The aims of today’s article by Savic et al. are to (1) discuss the risks and benefits of sugammadex and neostigmine for reversal of neuromuscular blockade and (2) review sugammadex, neostigmine, and neuromuscular-blocking drug (NMBD) allergy, because reversal agents are usually administered to patients who have received a NMBD, and NMBDs (in particular rocuronium) are a leading cause of anesthetic-related anaphylaxis worldwide. Treatment and the differential diagnosis are NOT discussed in this article so our reviewing authors refer the readers to download the Society for Pediatric Anesthesia’s PediCrisis App v2 from the SPA, iphone or android websites.