In today’s PAAD, Chang et al.(1) conducted an in vitro simulation using a standardized infusion circuit consisting of a 60-mL syringe, rigid infusion tubing, and two three-way stopcocks. They hypothesized that residual air within the syringe and vertical displacement of the syringe pump relative to the patient interacts with hydrostatic pressure gradients to cause transient flow rate variations, which may contribute to recurrent hemodynamic instability. As I read this, I kept thinking: “Why hasn’t anyone thought of studying this before?” Myron Yaster MD

A couple of years ago our hospital, Stanford University, went through the process of selecting a new infusion pump vendor. In the process of doing this, I learned that depending on the pump you are using, there can be considerable variation in the actual rate of infusion versus the set/displayed rate of infusion, so much so, that several of the most common pump vendors actually explicitly state this in their products’ instructions for use and teach this in their pump training! Full disclosure: I had never heard of this as a trainee, not even from my anesthesiologist-engineer mentors. This may not have mattered as much in adult patients, but with neonatal patients requiring concentrated vasoactive infusions with low flow rates, this can matter a lot! James Xie MD

Original article

Chang X, Sun J, Li Z, Jing J, Yuan T, Guan H, Zhang S, Xu X, Chen T, Liu J. The Effect of Syringe Pump Vertical Position and Residual Air on the Stability of Vasoactive Drug Infusion: A Simulation Study. Paediatr Anaesth. 2026 Aug;36(8):923-927. doi: 10.1002/pan.70198. Epub 2026 Apr 24. PMID: 42029004.

As you all know, precise delivery of vasoactive medications is essential for maintaining hemodynamic stability in critically ill pediatric and neonatal patients. Although syringe infusion pumps are designed to provide continuous and accurate drug administration, transient fluctuations in drug delivery frequently occur during clinical use. Previous investigations have primarily focused on pump mechanics, tubing compliance, and syringe changeover procedures.(2) Further, previous studies have attributed such instabilities to factors such as medication changeover procedures, tubing compliance, or variations in central venous pressure. (3) Recent work by Weiss et al. (4) demonstrated that vertical pump positioning significantly affects start-up fluid delivery through hydrostatic mechanisms. Chang et al. explored a less appreciated but clinically relevant source of infusion instability: the interaction between residual air within the syringe and vertical displacement of the syringe pump relative to the patient.

In today’s PAAD, Chang et al. conducted an in vitro simulation using a standardized infusion circuit consisting of a 60-mL syringe, rigid infusion tubing, and two three-way stopcocks (Figure). Four experimental conditions were examined: (1) no residual air with the infusion outlet positioned 25 cm below the syringe, (2) no air at 50 cm, (3) 1 mL of residual air at 25 cm, and (4) 1 mL of residual air at 50 cm. Flow instability was quantified by measuring droplet formation over 10-second intervals, with each condition repeated 30 times.

Okay, what did they find? Residual air markedly increased infusion instability. At a 25-cm height difference, introducing 1 mL of air increased the median droplet count from 0.25 to 0.75 (p < 0.001). At 50 cm, droplet output increased from 0.75 without air to 2.25 with air (p < 0.001). These findings demonstrate that even a small amount of residual air substantially amplifies transient flow disturbances.

Vertical displacement independently influenced infusion performance. Increasing the height difference from 25 cm to 50 cm significantly increased flow, even in the absence of air, reflecting the effects of hydrostatic pressure. When residual air was present, the influence of height became even more pronounced, with median droplet counts increasing from 0.75 to 2.50 (p < 0.001). The combination of maximal vertical displacement and residual air produced the greatest variability in drug delivery. This suggests that compressible air amplified the hydrostatic disturbance.

Chang et al. propose that residual air functions as a compressible buffer within the infusion system. Small changes in hydrostatic pressure resulting from vertical movement of the syringe pump compress or expand the trapped air, producing transient surges or interruptions in drug flow. This mechanism may explain clinically observed hemodynamic instability despite constant pump settings and meticulous medication preparation.

What does this mean in your practice? These findings reinforce several practical recommendations: Syringe pumps should be positioned at the intended clinical height before the infusion system is primed, meticulous elimination of residual air should occur after final positioning (which includes taking into account the bed height relative to the pump), and the pump should remain at approximately the level of the patient’s right atrium throughout vasoactive drug administration. These measures may reduce hydrostatic pressure changes and improve the consistency of drug delivery, particularly in neonates and critically ill children receiving low-flow vasoactive infusions.

Perhaps the most humbling lesson is that the pump display is digital, but the drug-delivery system remains an analog hydraulic circuit. BD’s Alaris instructions advise keeping the Syringe Module level with the patient’s heart and warn that raising it may transiently increase delivery or cause a bolus, whereas lowering it may cause under-infusion; its priming guidance also emphasizes expelling all air. (5) B. Braun gives nearly identical guidance for the Perfusor Space and even cautions that rotating a running pump between horizontal and vertical positions may transiently increase delivery.(6) When every pump cannot be at heart level, the lowest-rate, high-risk or life-sustaining infusions should be prioritized closest to the heart or catheter tip. Gravity, gas compressibility, syringe friction and compliance, tubing dead space, and downstream pressure do not disappear when we hit the “start” infusion button. In other words, the programmed rate is not a guarantee of perfectly steady instantaneous delivery at the catheter tip.

What infusion pumps do you use and have you read through their instructions for use in detail? Were you trained specifically to adjust infusion pump height relative to a patient’s heart (due to potential impact on infusion rate) and expel all air from your infusion line tubing given its potential impact of fluid dynamics (not just for micro emboli risk)? Finally, we are firm believers in understanding how the devices we use work - otherwise we are just technicians, not anesthesiologists.

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

PS: I (MY) asked James if it would make a difference if the pumps were positioned horizontally or vertically? His response: “this particular in vitro experiment was conducted with the infusate in horizontal position. When flipping to vertical, the additional pressure exerted from the vertical column of fluid will certainly have an effect on the actual infusion rate. (BBraun specifically cautions about changing the horizontal/vertical orientation in their IFU).”

References

1. Chang X, Sun J, Li Z, Jing J, Yuan T, Guan H, et al. The Effect of Syringe Pump Vertical Position and Residual Air on the Stability of Vasoactive Drug Infusion: A Simulation Study. Paediatric anaesthesia. 2026;36(8):923–7. Epub 20260424. doi: 10.1002/pan.70198. PubMed PMID: 42029004.

2. Poiroux L, Le Roy C, Ramelet AS, Le Brazic M, Messager L, Gressent A, et al. Minimising haemodynamic lability during changeover of syringes infusing norepinephrine in adult critical care patients: a multicentre randomised controlled trial. British journal of anaesthesia. 2020;125(4):622–8. Epub 20200729. doi: 10.1016/j.bja.2020.06.041. PubMed PMID: 32739045.

3. Lucchini A, Elli S, Burgazzi A, Malvestuto Grilli L, Pes C, Ferrari K, et al. Simulated haemodynamic parameters and different infusion set-up affect drug delivery during syringe pump change over: A bench-top study in a laboratory setting. Intensive Crit Care Nurs. 2025;86:103861. Epub 20241017. doi: 10.1016/j.iccn.2024.103861. PubMed PMID: 39418877.

4. Weiss M, Wendel-Garcia PD, Grass B, Buehler PK, Kleine-Brueggeney M. Effect of vertical pump position on start-up fluid delivery of syringe pumps used for microinfusion. Paediatric anaesthesia. 2023;33(12):1099–107. Epub 20230905. doi: 10.1111/pan.14750. PubMed PMID: 37668096.

5. Becton, Dickinson and Company. BD Alaris™ System with Guardrails™ Suite MX User Manual Addendum. Part No. P00000484-01. July 2020:12–13. (https://www.bd.com/content/dam/bd-assets/na/medication-management-solutions/documents/user-guide/mms_if_bd-alaris-system-user-manual-addendum-v9-1-12-1-0_ug_en.pdf)

6. B. Braun Medical Inc. Perfusor® Space® and Accessories: Instructions for Use. US; software 588U:12–14. (https://www.bbraunusa.com/content/dam/catalog/bbraun/bbraunProductCatalog/S/AEM2015/en-us/b3/perfusor-space-syringepump-nextgenerationsoftwareu.pdf)

In today’s PAAD, Luo et al.(5) took advantage of the 2024, national, U.S. intravenous fluid shortage crisis to determine whether formula-based deficit replacement is necessary to maintain intraoperative stability or postoperative recovery. Luo et al work at Nemours Children’s Health, which because of the national IV fluid shortage implemented an institution-wide reduction in routine fasting-deficit replacement, creating a natural experiment to evaluate the clinical consequences of a more restrictive fluid strategy. I/we think this was a great example of turning lemons into lemonade. Myron Yaster MD

Original article

Luo XS, Mason M, Chan S, Minneci PC, Russo K, Steinmetz K, Olbrecht VA. Routine Replacement of Fasting Deficits in Pediatric Ambulatory Anesthesia: A Propensity-Matched Retrospective Cohort Study. Paediatr Anaesth. 2026 Jul 13. doi: 10.1002/pan.70261. Epub ahead of print. PMID: 42439603.

This retrospective propensity score-matched cohort study included 8,508 pediatric ambulatory anesthetics (4,254 before-May to September 2024-and 4,254 after the practice change -October 2024 to March 2025) selected from 9,640 procedures performed between May 2024 and March 2025. Emergency cases were excluded. Specific recommendations during the shortage (post) period) included use of a saline lock without a running crystalloid infusion for short procedures and the use of smaller intravenous fluid bags to limit total administered volume. Matching balanced age, sex, ASA status, weight, procedure duration, surgical specialty, and hospital location.

The mean age of the patients in this study was 7.2 years in both cohorts (SMD −0.005), confirming excellent age balance. The most common procedures were tonsillectomy and adenoidectomy, and upper gastrointestinal endoscopy. Mean procedure duration was 31min (SD 39min). Otolaryngology, gastroenterology, urology, orthopedics, and general surgery accounted for approximately 90% of cases in both cohorts.

Implementation of the restrictive fluid strategy produced a 38.1% reduction in intraoperative crystalloid administration, with median fluid administration decreasing from 9.0 to 4.6 mL/kg across all surgical services (p<0.001) (figure). When distributed according to the type of surgery, the median volume of IV fluids varied from 4.4 to 15.5 mL/kg in the pre period and from 0.6 to 8 mL/kg in the post period.. Despite this substantial reduction in fluid administration, overall vasopressor use was unchanged (adjusted OR 1.13; 95% CI 0.92–1.38), PACU rescue antiemetic use remained rare (0.2% vs. 0.1%), PACU length of stay was essentially identical (59.7 vs. 59.0 minutes) and Emergency department visits within 24 hours were similarly uncommon (0.3% vs. 0.2%).

Figure legend: Distribution of intraoperative crystalloid volume administered in the pre- and post-intervention cohorts, partitioned by the surgical service line. The outer shape of the violin represents the kernel density estimate. Within the violin, a box plot provides the range, median, and interquartile ranges for each cohort. Dark and light shading represent the pre- and post-intervention cohorts, respectively.

An interesting secondary finding was a modest increase in phenylephrine administration after implementation of the restrictive fluid protocol (adjusted OR 1.43), whereas ephedrine use remained unchanged. The authors suggest this likely reflects clinician preference for treating anesthesia-induced vasodilation with vasopressors rather than administering additional crystalloid, rather than evidence of clinically important hypovolemia.

These findings challenge the traditional assumption that routine formula-based fasting deficit replacement is necessary during short ambulatory pediatric procedures. Instead, they support an individualized approach in which intravenous fluids are administered according to the patient’s clinical condition rather than automatic calculations derived from maintenance fluid formulas.

The authors emphasize that the Holliday–Segar formula estimates maintenance water requirements, not intravascular volume depletion, and that intraoperative hypotension during pediatric anesthesia is more commonly related to anesthetic-induced vasodilation than fasting-associated hypovolemia.

To be honest, we are not surprised by these findings and applaud Luo et al. for this study. For short procedures, after which oral intake is usually rapidly allowed, replacement of preoperative fluid deficits based on the Holliday–Segar (4-2-1) formula is unnecessary. This doesn’t mean that you don’t need to place an IV, which can be crystalloid locked or to a syringe with 10-20 mL of fluid, but administering a large amount of fluid is just a waste of money as most of it will escape in the extravascular space in less than 1 hour. It would be interesting to know what the IV replacement and maintenance practice was followed during the pre period and whether there was any difference in the delay to first postoperative micturition between these two periods.

The conclusion from Luo et al. that maintenance fluids can safely be omitted for short procedures corroborates the results from a prospective observational study from three German centers in which a regime of routinely omitting IV maintenance fluids in children undergoing “short anesthesia” was evaluated (6). The authors recorded fasting times and various hemodynamic and biochemical outcomes. They reported low rates of hypotension, hypoglycemia and ketosis in 420 children of roughly the same age as in Luo et al.´s study, but there was no control group.

Thus, two large studies from different settings both suggest that IV maintenance fluids can be safely omitted for short procedures or ambulatory surgery. Nevertheless, it makes sense to not to throw out the baby (at least not all of them) with the bath of Ringers, to paraphrase the German expression. Better to base the decision of whether or not to start an IV infusion on the actual preoperative fasting time and the general condition of the individual patient.

What do you think? Are you ready to abandon the routine practice of replacing fluid deficits base on the Holliday–Segar (4-2-1) formula? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823–32. Epub 1957/05/01. PubMed PMID: 13431307.

2. Frykholm P, Disma N, Andersson H, Beck C, Bouvet L, Cercueil E, et al. Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. European journal of anaesthesiology. 2022;39(1):4–25. doi: 10.1097/eja.0000000000001599. PubMed PMID: 34857683.

3. Frykholm P, Bjurström MF. 6-4-2 or 6-4-0: In which direction should we go? Acta anaesthesiologica Scandinavica. 2025;69(3):e14581. doi: 10.1111/aas.14581. PubMed PMID: 39960268.

4. Joshi GP. Preoperative Strategies for Patients on Glucagon-like Peptide-1 Receptor Agonists Navigating Current Controversies and Future Directions. Anesthesiology. 2024;141(6):1031–3. doi: 10.1097/aln.0000000000005222. PubMed PMID: 39471348.

5. Luo XS, Mason M, Chan S, Minneci PC, Russo K, Steinmetz K, et al. Routine Replacement of Fasting Deficits in Pediatric Ambulatory Anesthesia: A Propensity-Matched Retrospective Cohort Study. Paediatric anaesthesia. 2026. Epub 20260713. doi: 10.1002/pan.70261. PubMed PMID: 42439603.

6. Vetter L, Sümpelmann R, Rudolph D, Röher K, Vetter M, Boethig D, et al. Short anesthesia without intravenous fluid therapy in children: Results of a prospective non-interventional multicenter observational study. Paediatric anaesthesia. 2024;34(5):454–8. Epub 20240125. doi: 10.1111/pan.14847. PubMed PMID: 38269449.

The shots have been approved for people 65 and older, and for younger people with underlying conditions. Others may be able to get them off label.

https://www.nytimes.com/2026/08/27/well/live/covid-vaccines-fall-2026.html?campaign_id=60&emc=edit_na_20260827&instance_id=181061&nl=breaking-news&regi_id=4608777&segment_id=225530&user_id=d261a49fee4e3394c4f81d3a3f01f8a1

How effective are the vaccines?

The updated vaccines target the XFG variant of Covid, as an F.D.A. committee recommended this spring. That should be a good match for the virus that is circulating, said Dr. Ian Mellis, an assistant professor of pathology and cell biology at Columbia University.

XFG is the most common variant in North America as of late August, and closely related variants account for most other cases, Dr. Mellis said. One variant, BA.3.2, is less related but is decreasing.

When should I get one?

There isn’t a clear consensus. Ask your doctor if you’re not sure about timing, especially if you’re in a higher-risk group. (If you had Covid recently, wait three months.)

Dr. William Schaffner, a professor and infectious disease specialist at Vanderbilt University Medical Center, said October was the ideal time for both Covid and flu shots, to provide the best protection during the respiratory virus season. Protection wanes after a few months.

But Dr. Peter Chin-Hong, a professor and infectious disease specialist at the University of California, San Francisco, recommended that high-risk people get vaccinated against Covid as soon as the new shots are available, while waiting until October for a flu shot. (It would be reasonable for people under 65 with no high-risk conditions to time their Covid shot more “strategically” ahead of the holidays or travel, he said.) While we can expect a winter wave, he noted, there is also a summer wave happening now.

We were delighted to see a PAAD focused on error traps in pediatric neuromuscular blockade hee. The review in Pediatric Anesthesia and PAAD highlight several important challenges when using neuromuscular blockade in pediatric anesthesia practice and emphasizes the critical role of quantitative train-of-four (TOF) monitoring in improving patient safety. However, we believe the true impact and feasibility of quantitative TOF monitoring in pediatric anesthesiology may still be underestimated. At our center, we began a quality improvement initiative in 2023 to increase TOF monitoring before the universal implementation of electromyography-based TOF (EMG TOF). Prior to this effort, monitoring rates were approximately 50% across all pediatric age groups, with the lowest rates among infants. This is likely not unique to the Johns Hopkins Children’s Center. Following universal EMG TOF implementation in fall 2025, monitoring rates have increased to over 80% overall and in many cases, changed our (SRK) routine clinical practice

In our experience, EMG TOF has proven reliable, easy to use, and minimally disruptive to workflow. However, having access to the technology alone is insufficient. Alongside evidence-based guidelines, clinicians require adequate institutional and clinician support, including monitor availability, education, and strategies to address barriers to implementation. Data is forthcoming! Our experience has shown that universal quantitative monitoring is feasible, sustainable, and essential for improving the safety of pediatric patients receiving neuromuscular blockade, and we hope that more centers will consider establishing EMG TOF as their standard practice.

From Dr Andrea Santoro, Senior VMO Anaesthetist | Department of Anaesthesia, Pain and Peri-operative Medicine, Level 4, ASB, Royal North Shore Hospital, Reserve Road, St Leonards, New South Wales 2065 Office 8436 7613

I read the Uchinami et al. trial and the accompanying Rowland et al. editorial here with real interest, and I agree the first-pass success data for VL in the hands of novice trainees are hard to argue with. But I want to push back on the framing used to introduce the piece, and offer a different lens for thinking about where this technology should sit in training.

The comparison to giving up vinyl and CDs for streaming doesn’t hold up, and the distinction matters. Choosing a format to listen to music is a consumption decision, it changes nothing about the listener’s own skill. Laryngoscopy is not a consumption decision; it’s a psychomotor and perceptual-cognitive skill that depends on integrating visual, proprioceptive, and spatial information in real time, under a time pressure set by a desaturating infant. The analogy quietly elides the difference between adopting a better delivery technology and acquiring a difficult manual skill, and that elision is exactly the direction this discussion shouldn’t be allowed to drift in.

I’d offer a different analogy: a pilot learning manual, “hand-flown” instrument flying on a simple aircraft before progressing to a complex fly-by-wire, glass-cockpit platform. Aviation has spent decades relearning the hard way — the “children of the magenta line” problem — that automation built to make the job easier can also erode the raw manual and perceptual skill that automation depends on being available to catch you when technology fails. I think direct laryngoscopy sits in exactly that category: a technically harder, more demanding skill than VL, not a deprecated predecessor to it, and one whose value shows up precisely in the moments the video image isn’t there to rely on.

Where I am genuinely enthusiastic about VL is as a teaching tool, specifically because it lets the instructor see what the trainee is seeing directly, unmediated by a screen, in real time. That’s an enormous advance in our ability to coach, correct, and give precise feedback during the exposure itself, in a way that simply wasn’t possible when only the trainee’s eyes had the view.

My concern is the generation on the other side of this transition. If VL becomes the default and DL becomes an afterthought, we risk producing anaesthetists who are excellent at a screen-mediated task and genuinely deskilled at the direct one — and DL is precisely what you reach for when the video isn’t available or isn’t usable: device or battery failure, a soiled or blood-obscured camera in major trauma, a post-tonsillectomy bleed where the lens fouls faster than it can be cleared, or resource-limited settings without VL access at all. Rowland et al. themselves caution that VL shouldn’t replace comprehensive airway education — I’d go further and argue that DL proficiency needs to be a deliberately preserved and separately assessed competency in training programs, not something we assume will happen incidentally alongside VL-first teaching.

None of this argues against Uchinami et al.’s findings, or against making VL the default teaching tool for novices. It argues for being explicit, as training programs, about maintaining a genuine minimum standard of hands-on DL competence, measured on its own terms, even as VL becomes the routine first choice.

From Diane Wood Gordon MD, University of Colorado | Children’s Hospital Colorado

One persistent legacy of the halothane era here is the way mask induction is still taught in many places. That is, with co-administration of nitrous oxide (N2O) and with high fresh gas flows (FGF).[1] High FGF were necessary to assure rapid reflection of the vaporizer setting to the distal end of the circuit-- because as Dr Friesen noted, the myocardium infants is very susceptible to the depressant effects of Halothane[2], and when the heart rate began to decrease it was vital to be able to rapidly reduce the concentration of halothane being administered-- hence the high FGF! As for N2O, in high concentrations, it provides a significant percentage of MAC and doesn’t come with that scary myocardial depressant side effect profile, so it added a margin of safety to balance the known risk of myocardial depression due to Halothane. Co-administering halothane with N2O also produced a 2nd gas effect that is much more pronounced for an agent with higher solubility (halothane). So it’s understandable that N2O and high FGF were important components of pediatric mask induction when Halothane was used!

But let’s remember that Halothane is long-gone, and Sevoflurane has a much different set of chemical properties and resulting clinical characteristics. Sevoflurane’s safety profile and therapeutic window are much preferable to Halothane’s, making FGF above minute ventilation and co-administration of N2O to provide a fraction of MAC without myocardial depression both unnecessary. Additionally, because Sevoflurane is much less soluble than Halothane, the 2nd gas effect of N2O plays a minimal role in increasing concentration of sevoflurane in the alveoli during mask induction.

Knowing where our teachings and clinical habits come from is important-- and so is the willingness to adapt our practice to address more pertinent safety concerns. As Halothane-induced myocardial depression leading to cardiac arrest is no longer the most pressing concern during induction, our clinical practice should adapt to providing high FiO2 during pediatric mask induction (avoiding N2O) as is standard of care during adult induction, and using FGF that match minute ventilation in order to reduce environmental pollution and occupational exposure.

1. Gordon D, Feldman J. Environmentally responsible mask induction. Best Pract Res Clin Anaesthesiol. 2025 Feb 7. http://dx.doi.org/10.1016/j.bpa.2025.02.001

2. Friesen RH, Lichtor JL. Cardiovascular depression during halothane anesthesia in infants: study of three induction techniques. AnesthAnalg. 1982;61(1):42–5.

From David O. Warner, M.D. Mayo Clinic

I enjoyed the PAAD eulogizing halothane here. I wanted to point out that clinical outcomes with halothane were remarkably favorable in experienced hands. My parents, Jack and Louise Warner, and colleagues published a retrospective study of the first 25 years of halothane anesthesia in a busy pediatric hospital (now Nationwide Children’s Hospital in Columbus, OH).[1] They reviewed over 200,000 cases, finding life-threatening complications due to side effect in only fifteen patients. These “…could be grouped into three areas: hepatitis (one), malignant hyperfhermia (ten), and cardiac arrhythmias (four). No child died or sustained permanent sequelae. In eleven instances, other drugs (succinylcholine, atropine, cocaine, and epinephrine) possibly contributed to the adverse reactions.” So there is no doubt that the cardiac depressant effects of halothane were real (I had a few scary moments in my own career), but halothane represented a remarkable advance in pediatric (and adult) practice – and I still miss it!

1. Warner LO, Beach TP, Garvin JP, Warner EJ. Halothane and children: the first quarter century. Anesth Analg. 1984 Sep;63(9):838-40. PMID: 6465580.

Original article

Pearsall MF, Feldman JM. When does apparatus dead space matter for the pediatric patient? Anesth Analg. 2014 Apr;118(4):776-80. doi: 10.1213/ANE.0000000000000148. PMID: 24651232.

During anesthesia, it can be challenging to achieve the goals of side-stream gas sampling and humidification of the airway while minimizing apparatus dead space, especially in small patients. Apparatus dead space consists of the internal volume of components added to the breathing system between the y-piece and the endotracheal tube. The impact of apparatus dead space in the breathing circuit is a problem when ventilating small patients that is “hiding in plain sight.”  When apparatus dead space is greater than desired, the result will be hypercarbia, which may go unrecognized since the end-tidal CO₂ measurement will not reflect the elevated P_aCO₂.²

In this issue of the PAAD, we revisit prior literature on the relationship between apparatus dead space and the effectiveness of mechanical ventilation in pediatric patients.  Guidance for managing apparatus dead space according to patient size is reviewed, including recent changes to the supply of low dead space endotracheal tube connectors.

In today’s classic paper, Pearsall and Feldman measured and reported the dead space of some commonly used connectors that impact apparatus dead space in the anesthesia circuit.¹ These connectors are used to sample airway gases for analysis, provide heat and moisture exchange (HME), and make the circuit connection to the endotracheal tube more convenient.  In addition, the authors developed a simple one-compartment model to estimate the impact of apparatus dead space on alveolar CO₂ (P_ACO₂) by patient size.  The model demonstrates that there is an exponential rise in P_ACO₂ if minute ventilation is unchanged as dead space increases.  An earlier in vivo study of the impact of adding a large HME to the breathing circuit showed results similar to those estimated by the model in small patients.³  Not unexpectedly, these references show that increasing apparatus dead space has a more significant impact on P_ACO₂ in smaller patients than in larger patients. (Figure 1).

Legend:  Family of plots estimating the impact of increasing apparatus dead space on P_ACO₂ by patient size when minute ventilation remains constant.¹

The model is also used to show it may be possible to offset the increase in P_ACO₂ to some degree by increasing minute ventilation, but there are disadvantages to this approach.  The primary disadvantage is exposing the lung to greater energy than would otherwise be needed, potentially increasing the risk of ventilator-induced lung injury, especially in vulnerable populations that have underlying lung disease.⁴  Further, if apparatus dead space becomes too great, CO₂ cannot be controlled reliably by increasing minute ventilation.  Whereas many healthy patients will tolerate hypercarbia quite reasonably, that is not true for all patients.  Patients with a reactive pulmonary circulation at risk for pulmonary hypertension as well as those with intracranial pathology require careful control of P_aCO₂.  Given the challenges of mechanical ventilation when caring for pediatric patients with specific pathology or undergoing complex procedures, managing apparatus dead space well removes one consideration when it becomes challenging to achieve good gas exchange.  A more recent publication by King and Feldman provides further guidance for managing apparatus dead space effectively for all sizes of patients.⁵

In this paper, King and Feldman briefly review the physiology of dead space, summarizing the relationship between patient size and the impact of apparatus dead space on ventilation, specifically elimination of CO₂.⁵  The authors specifically draw attention to the need to sample gases for analysis during anesthesia care, maintain humidity in the lungs and the potential dead space penalty imposed by devices used to achieve those goals.  Using a rule of thumb to limit apparatus dead space to one-third of the desired tidal volume, guidance is provided for managing apparatus dead space by patient size.  Three categories of recommendations are provided for minimal dead space (<5 Kg), low dead space (5-15 Kg), and normal dead space (> 15 Kg).  (Figure 2).

Legend:  Guidance for managing breathing circuit devices commonly used during anesthesia that impact apparatus dead space for different size patients.⁵

Our tiniest patients are typically the most vulnerable and require unique solutions.  This is certainly true when managing apparatus dead space for patients who weigh less than 5 kg.  Specifically, the best solution recommended by King and Feldman for these small patients has been to exchange the endotracheal tube connector with a low dead space version with an integrated gas sampling port.  Combining this connector with a small dead space dedicated heat and moisture exchanger achieves the goals of gas sampling and humidification with minimal added dead space. (Figure 3) When using these devices, capnography becomes as reliable as possible for estimating P_aCO_2, and if hypercarbia ensues, attention can be directed to ensuring minute ventilation is adequate without concern for the impact of apparatus dead space. 

Legend: Example of 15 mm endotracheal tube connector with gas sampling port that can be used without increasing apparatus dead space.  (Smith’s Medical – No longer manufactured)

Supply Chain and the Small Dead Space Connector

The unique endotracheal tube connector in Figure 3 was originally manufactured by Portex, which was acquired by Smith’s Medical and ultimately became part of ICU Medical.  Unfortunately it is no longer manufactured or available as a standalone product.  Rather, it is now manufactured and packaged with an appropriately sized uncuffed endotracheal tube.(figure 4). 

Legend:  Smiths Medical Endotracheal Tube Murphy with Low Dead Space Sideport Connector

Pediatric devices are always susceptible to the orphan device problem when the potential market size is too small to justify the expense of manufacturing and distributing a medical device.  While it appeared that the low dead space connector had fallen prey to this problem, fortunately, the device was repackaged to include an uncuffed endotracheal tube as well.  While it may seem more convenient to have the connector and tube together, we believe it is more convenient and environmentally friendly to have them packaged separately.  It is not uncommon to trial different endotracheal tube sizes in a small patient and traditionally, we were able to reserve the low dead space connector until the proper size tube was determined.  It is also our preference to use cuffed endotracheal tubes as they provide the most flexibility for ensuring reliable ventilation without leaks, especially in the dynamic environment of the operating room.  Also, for patients who remained intubated after the procedure, the gas sampling connector is removed, and the original connector replaced to avoid a source of an unidentified leak in the ICU setting. Patients who come to the OR from NICU already intubated could receive a unique connector in theatre, without the need of a new tube as well.  While we are pleased to be able to have a continued source of these connectors, it is quite likely that the endotracheal tube supplied with the connector will go unused.

The low dead space endotracheal tube connector, especially for patients under 5 kg, remains a convenient low-cost solution to sampling respiratory gases without increasing apparatus dead space.  Fortunately, the device solution remains available, albeit only as part of a  more wasteful package. 

References

1.          Pearsall MF, Feldman JM. When does apparatus dead space matter for the pediatric patient? Anesthesia and analgesia 2014;118(4):776-80. (In eng). DOI: 10.1213/ane.0000000000000148.

2.          Humphreys S, Schibler A, von Ungern-Sternberg BS. Carbon dioxide monitoring in children-A narrative review of physiology, value, and pitfalls in clinical practice. Paediatric anaesthesia 2021;31(8):839-845. (In eng). DOI: 10.1111/pan.14208.

3.          Chau A, Kobe J, Kalyanaraman R, Reichert C, Ansermino M. Beware the airway filter: deadspace effect in children under 2 years. Paediatric anaesthesia 2006;16(9):932-8. (In eng). DOI: 10.1111/j.1460-9592.2006.01895.x.

4.          Cressoni M, Gotti M, Chiurazzi C, et al. Mechanical Power and Development of Ventilator-induced Lung Injury. Anesthesiology 2016;124(5):1100-8. (In eng). DOI: 10.1097/aln.0000000000001056.

5.          King MR, Feldman JM. Optimal management of apparatus dead space in the anesthetized infant. Paediatric anaesthesia 2017;27(12):1185-1192. (In eng). DOI: 10.1111/pan.13254.

From Jeff Feldman, MD, MSE, FASA

In a prior PAAD here that Myron is reposting today, we reviewed articles on managing dead space in neonates and small infants and highlighted supply chain changes for
obtaining the small dead space sampling endotracheal tube connector
recommended in the paper.(1,2) . In essence, the connector that had been available as a low-cost standalone option (top figure below) is now only available if purchased with an uncuffed endotracheal tube. A quick search revealed that option is
still manufactured by Smith's Medical and available from a variety of
distributors.

Draeger medical manufactures an option that should be easily available
and likely lower cost than the endotracheal tube with connector (bottom figure below). The name of the product is HME Humidstar 2 Plus Luer-Lock, Reference
#MP05840. For what it is worth, Draeger has published a clinical
review of the device. While slightly greater dead space than the
sampling endotracheal tube connector, the Draeger product includes HME
capability and should be suitable for patients less than 5 Kg.
Specifications indicate it is suitable for tidal volumes from 10-50
mLs. Interestingly, the magnitude of the dead space is not listed in
the specifications but it is similar to the HME options with the
smallest dead space around 2 pls described in the King article (2).

We are fortunate to have options for minimizing apparatus dead space
in the smallest patients while still sampling gases and providing heat
and moisture exchange. This is an important consideration, not only
for obtaining reliable capnograms, but also for facilitating a lung
protective ventilation strategy. Added dead space increases the
minute ventilation required to achieve adequate ventilation exposing
the lung to even greater stress from the ventilator.

Smiths medical device

Draeger medical device

References

1. Pearsall MF, Feldman JM. When does apparatus dead space matter for the pediatric patient? Anesthesia and analgesia 2014;118(4):776-80. (In eng). DOI: 10.1213/ane.0000000000000148.

2. Humphreys S, Schibler A, von Ungern-Sternberg BS. Carbon dioxide monitoring in children-A narrative review of physiology, value, and pitfalls in clinical practice. Paediatric anaesthesia 2021;31(8):839-845. (In eng). DOI: 10.1111/pan.14208.

This is a very short article from the ASA Monitor that is well worth your time to read in its entirety. Myron Yaster MD

Tkachenko I, Hasan A, Rafique MB. The Rise of Part-Time Anesthesiologists ASA Monitor. 2026;90(8):1-8. doi:10.1097/01.ASM.0001238704.40189.da

Tkachenko et al. describe a cultural shift in anesthesiology toward part-time employment, reduced clinical full-time equivalents (FTEs), and flexible scheduling. Younger physicians increasingly prioritize work-life integration and caregiving, while senior anesthesiologists may use reduced schedules as a pathway to phased retirement. Given anesthesiology’s high rates of emotional exhaustion and professional fatigue (AKA burnut), reduced clinical workloads may improve wellness, job satisfaction, engagement, and career longevity.

However, widespread reductions in clinical effort have important workforce implications. Maintaining equivalent operating-room capacity and call coverage requires proportionally more clinicians, potentially worsening surgical delays, procedural backlogs, and disparities in underserved areas. Reduced physician availability may also accelerate reliance on nonphysician anesthesia providers and alter physician leadership within perioperative medicine. These concerns are amplified by AAMC projections of a 13,500–86,000 U.S. physician shortage by 2036.

The authors conclude that the central issue is not whether part-time practice should exist, but how to reconcile physician well-being and career sustainability with society’s need for continuous access to care. Potential strategies include expanded GME positions, redesigned call systems, and deliberate workforce planning.

Dear SPA Members,

Please find details regarding the SPA approved survey participation request which went out recently. This voluntary survey is for SPA members only. This is a request to complete the survey if you have not already done so (a Big Thank you if you have already filled it). The SPA- QS NPO work group deeply appreciates your time in completing this survey. The details of the survey and link are below.

Thank you

Sincerely

Joseph Sisk, MD, FAAP Project Lead, SPA-QS Associate Professor, Department of Anesthesiology and Pediatrics, University of North Carolina at Chapel Hill

Priti Dalal, MD, FRCA, FAAP, Chair, Society for Pediatric Anesthesia Quality and Safety Committee, Professor, Department of Anesthesiology, Penn State College of Medicine

“Anesthesiologists practicing in the United States have largely adopted the 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. These guidelines were aimed to minimize the risk of anesthesia-related complications such as pulmonary aspiration in healthy patients undergoing elective procedures. Although the current nil per os (NPO) guidelines are intended to be comprehensive, many clinical situations specific to the pediatric population are left ambiguous. To address challenging situations not addressed in the ASA guidelines, the Society for Pediatric Anesthesia Quality and Safety Committee has formed the NPO Guidelines workgroup. The goal of this workgroup is to identify appropriate NPO times for common clinical scenarios.

While we endeavor to use published evidence wherever possible, it is clear that not all NPO practices can be supported by existing literature. As such, this workgroup has developed a survey to assess the practices of current SPA members when confronted with ambiguous clinical guidelines.

This is a research survey. The results will be included in a review article addressing common NPO concerns. Being a participant in this study may not immediately help or provide benefit to you, however with your participation we hope to improve the care of pediatric patients. There is no remuneration provided for participation in this study. By completing this survey, you are giving your consent to participate in the research study as described above. This survey is voluntary. All research includes the risk of breach of confidentiality. To mitigate this risk, no identifying information is required to complete the survey, and none will be collected.

This survey consists of 28 clinical questions and 10 demographic questions. It should take approximately 10-15 minutes to complete. There will be an opportunity to leave comments at the end.”

Please access the survey by clicking the link below or using the QR code:

Survey Link: https://unc.az1.qualtrics.com/jfe/form/SV_8jC1OUU5cOW8tLM

Alpha-Gal Syndrome and Blood Transfusions

From Nancy Finnel

Transfusion-related alpha-gal syndrome (TRAGS) is a newly recognized risk where patients with blood type O living in high-prevalence tick areas face an increased chance of severe allergic reactions when receiving Group B or AB plasma or platelets. Patients with type O blood who receive minor-incompatible plasma or platelets (Group B or AB) can experience severe, unexpected allergic or anaphylactic reactions if they carry pre-existing anti-alpha-gal IgE antibodies from tick bites.

Reference

Kaufman RM, Hoen AG, Khan J, et al. Epidemiologic Study of Transfusion-Related Alpha-Gal Syndrome. JAMA Intern Med. Published online August 24, 2026. doi:10.1001/jamainternmed.2026.3983

There is even less evidence for efficacy in pediatric pain.(5) Despite this, gabapentin is widely used off-label in pediatric pain practice, particularly for chemotherapy-induced neuropathic pain and as a perioperative opioid-sparing adjunct in scoliosis surgery. In a landmark RCT randomized controlled trial, Rusy et al. (6) using gabapentin 15 mg/kg preoperatively then 5 mg/kg TID for 5 days showed significantly lower morphine consumption in the recovery room and on postoperative days 1–2, with lower initial pain scores. No differences in opioid-related side effects were observed.

In today’s PAAD, Sutherland et al.(1) using the Optum Clinformatics Data Mart database (a private insurance claims database), took another look and evaluated perioperative prescribing patterns of gabapentin and opioids among adolescents undergoing common surgical procedures in the United States between 2012 and 2022. The study addresses whether perioperative gabapentin functions as an effective opioid-sparing adjunct in pediatric patients or merely adds another medication with limited benefit and potential harm. Myron Yaster MD

Original article

Sutherland TN, Candon M, Rabbitts JA, Newcomb C, Hadland SE. Gabapentin and Opioid Prescribing Trends among Adolescents Undergoing Common Procedures: A National Retrospective Cohort Study. Anesthesiology. 2026 Aug 1;145(2):313-321. doi: 10.1097/ALN.0000000000006079. Epub 2026 Apr 6. PMID: 41944587; PMCID: PMC13318171.

Sutherland et al. identified 181,225 opioid- and gabapentin-naïve adolescents (11–21 years) undergoing seven common procedures associated with postoperative pain or persistent opioid use, including spinal fusion, fracture repair, knee arthroscopy, colorectal surgery, incision and drainage, endoscopy, and hardware removal. Outcomes included initial prescriptions, refill rates within 60 days, prescription duration, pill counts, and the association between gabapentin use and subsequent opioid refills. Data was obtained from the Clinformatics Data Mart Database ( Optum Inc. (USA), which contains medical and pharmacy claims data for more than 15 million annual U.S. enrollees; adolescents were all privately insured.

Among the cohort, 32.1% (58,139) filled a perioperative analgesic prescription. Of these patients, 96.7% received opioids alone, 1.1% (662) received gabapentin alone, and 2.2% (1267) received both medications. Although opioid prescribing steadily declined throughout the study period, gabapentin prescribing increased beginning around 2016, both as monotherapy and in combination with opioids. These divergent prescribing trends likely reflect increasing efforts to limit opioid prescribing and dispensing and incorporate multimodal analgesia into perioperative practice.

OK, what did they find? Increasing gabapentin use did not achieve the anticipated opioid-sparing effect. Adolescents prescribed both gabapentin and opioids were significantly more likely to require an opioid refill than those receiving opioids alone (40.7% vs. 21.6%), corresponding to an adjusted probability difference of 13.9% after controlling for demographic and clinical variables. Furthermore, patients receiving combination therapy were prescribed longer opioid courses and larger opioid quantities, suggesting that gabapentin supplementation was associated with greater rather than reduced opioid exposure. However, more patients who received a gabapentin prescription were likely to have a comorbidity, including neuromuscular neurologic diagnoses, malignancy, anxiety, depression, pre-existing pain, history of SUD, or gastrointestinal disorders.

Gabapentin prescribing itself was notable for prolonged treatment. Initial prescriptions averaged approximately 20 days, over half exceeded 600 mg/day, and more than one-third of patients subsequently received a gabapentin refill. Whether this reflects the impact of pre-existing conditions or is unrelated cannot be determined from this study.

The study also identified continued opioid prescribing after procedures generally associated with mild or moderate postoperative pain, particularly endoscopy and incision and drainage, highlighting opportunities to further reduce unnecessary opioid exposure through adherence to pediatric prescribing guidelines.

These findings align with recent adult literature demonstrating limited analgesic benefit from perioperative gabapentinoids while emphasizing the recognized risks, including sedation, respiratory depression, misuse, diversion, and overdose (7), particularly when combined with opioids. Sutherland et al. conclude that routine perioperative gabapentin use in adolescents lacks convincing evidence of opioid-sparing benefit and should not be incorporated into multimodal analgesic protocols without a clear indication. Evidence-based multimodal strategies emphasizing acetaminophen, nonsteroidal anti-inflammatory drugs, regional anesthesia, and procedure-specific opioid stewardship should remain the cornerstone of pediatric postoperative pain management. However, I (RA) do believe that gabapentinoids have a role in both chronic and acute pain in selected patients and am not dissuaded by the results of this study. Their results appear to support the fact that adolescents with more comorbidities are more likely to experience pain and need analgesia for longer after surgery than those without preoperative conditions. Unfortunately, as with many retrospective database studies, it is impossible to know how much of either medication was actually consumed, and why refills were needed

Are you on the gabapentin bandwagon? Do you prescribe it for acute perioperative pain? Is it part of your ERAS protocols? Do you think it works? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Sutherland TN, Candon M, Rabbitts JA, Newcomb C, Hadland SE. Gabapentin and Opioid Prescribing Trends among Adolescents Undergoing Common Procedures: A National Retrospective Cohort Study. Anesthesiology. 2026;145(2):313–21. Epub 20260406. doi: 10.1097/aln.0000000000006079. PubMed PMID: 41944587; PubMed Central PMCID: PMC13318171.

2. Goodman CW, Brett AS. A Clinical Overview of Off-label Use of Gabapentinoid Drugs. JAMA internal medicine. 2019;179(5):695–701. doi: 10.1001/jamainternmed.2019.0086.

3. Wiffen PJ, Derry S, Bell RF, Rice ASC, Tölle TR, Phillips T, et al. Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews. 2017(6). doi: 10.1002/14651858.CD007938.pub4. PubMed PMID: CD007938.

4. Verret M, Lauzier F, Zarychanski R, Perron C, Savard X, Pinard AM, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology. 2020;133(2):265–79. doi: 10.1097/aln.0000000000003428. PubMed PMID: 32667154.

5. Egunsola O, Wylie CE, Chitty KM, Buckley NA. Systematic Review of the Efficacy and Safety of Gabapentin and Pregabalin for Pain in Children and Adolescents. Anesthesia and analgesia. 2019;128(4):811–9. doi: 10.1213/ane.0000000000003936. PubMed PMID: 30451725.

6. Rusy LM, Hainsworth KR, Nelson TJ, Czarnecki ML, Tassone JC, Thometz JG, et al. Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial. Anesthesia and analgesia. 2010;110(5):1393–8. Epub 2010/04/27. doi: 10.1213/ANE.0b013e3181d41dc2. PubMed PMID: 20418301.

7. Mattson CL, Chowdhury F, Gilson TP. Notes from the Field: Trends in Gabapentin Detection and Involvement in Drug Overdose Deaths - 23 States and the District of Columbia, 2019-2020. MMWR Morbidity and mortality weekly report. 2022;71(19):664–6. Epub 20220513. doi: 10.15585/mmwr.mm7119a3. PubMed PMID: 35552367; PubMed Central PMCID: PMC9098248.

As we discussed in a recent PAAD (July 3, 2026 https://ronlitman.substack.com/p/reader-response-and-news-that-you), hatlothane is no longer being produced and has been replaced by sevofluane. I thought that a review of its history explaining its benefits and why use of halothane continued for so many years. I also thought this PAAD would be a nice break while you read the PAAD with your morning coffee and for those in training it is a must read before you take your Board exams. Myron Yaster MD

Original article

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

This historical perspective reviews the physiologic basis for the heightened cardiovascular vulnerability of neonates and young infants to halothane anesthesia and explains how recognition of this interaction fundamentally changed pediatric anesthetic practice. Halothane, introduced in the late 1950s, rapidly replaced ether and cyclopropane because it was nonflammable, nonirritating to the airway, and well suited for inhalational induction in children. Despite an excellent overall safety profile, accumulating evidence demonstrated that halothane produced profound myocardial depression in neonates and infants, ultimately contributing to its replacement by sevoflurane.

The article emphasizes that the neonatal myocardium differs fundamentally from the mature heart.(1) Compared with adults, neonatal cardiac muscle contains approximately half the density of contractile myofibrils, markedly reduced sympathetic innervation with lower myocardial norepinephrine stores, impaired ventricular compliance, and immature sarcoplasmic reticulum calcium handling (figure). These developmental characteristics limit the infant heart’s ability to augment stroke volume and render cardiac output highly dependent on heart rate. Because halothane depresses myocardial contractility primarily through disruption of intracellular calcium flux,(2) its negative inotropic effects are amplified in the immature myocardium.

Figure legend: Top: Norepinephrine concentrations in the developing rabbit heart. Bottom: Frank-Starling curves of adult and fetal (at term) sheep heart preparations demonstrating lesser force of active contraction and greater resting tension in the fetal heart.(1)

Laboratory investigations consistently demonstrated this age-dependent susceptibility.(3) Experimental studies in neonatal rats showed myocardial failure at approximately half the myocardial halothane concentration required in adults, while isolated neonatal heart preparations exhibited equivalent depression of contractility at only half the anesthetic concentration. These findings established that the immature myocardium possesses substantially greater sensitivity to halothane than the mature heart.

Clinical investigations(4, 5) confirmed these experimental observations. During halothane induction, approximately 70% of infants younger than 8 weeks developed clinically significant hypotension, with susceptibility declining after approximately 10–17 weeks of age. Prospective studies reported mean decreases of 50% in systolic blood pressure and 30% in heart rate during induction in infants younger than 6 months. Pretreatment with atropine partially attenuated these changes, reinforcing the importance of heart-rate maintenance in neonatal cardiac output.(5) Furthermore, when equipotent anesthetic concentrations were compared across pediatric age groups, neonates and infants younger than 6 months experienced approximately 30% reductions in systolic blood pressure versus only 12%–15% in older children, suggesting that functional myocardial maturation occurs by about 6 months of age.

These physiological effects translated into measurable clinical risk. Historical data demonstrated that infants experienced substantially higher rates of intraoperative cardiac arrest than older children. In a large pediatric series, cardiac arrest occurred in approximately 1 in 360 neonates compared with 1 in 850 infants and 1 in 3,370 children aged 1–5 years.(6) Importantly, data from the Pediatric Perioperative Cardiac Arrest Registry identified medication-related events as the leading cause of anesthesia-related cardiac arrest, with halothane implicated in approximately two-thirds of these cases.(7)

The introduction of sevoflurane during the late 1990s marked the end of the halothane era. Comparative echocardiographic studies demonstrated significantly less myocardial depression with sevoflurane, and its adoption was accompanied by further reductions in pediatric anesthesia-related cardiac arrest (figure).(8, 9) The halothane experience remains an important lesson in developmental pharmacology, illustrating how age-dependent physiology can profoundly modify anesthetic drug effects and emphasizing the necessity of tailoring anesthetic management to the unique characteristics of the immature cardiovascular system.

Figure legend: Echocardiographic measurement of cardiac contractility in infants exposed to equipotent doses of halothane or sevoflurane.(9)

Perhaps most importantly, Friesen concludes: “As sevoflurane replaced halothane as the preferred inhalational anesthetic in children, the incidence of cardiac arrest in anesthetized infants declined further.”

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

References

1. Friedman WF. The intrinsic physiologic properties of the developing heart. ProgCardiovascDis. 1972;15(1):87–111.

2. Frazer MJ, Lynch C, 3rd. Halothane and isoflurane effects on Ca2+ fluxes of isolated myocardial sarcoplasmic reticulum. Anesthesiology. 1992;77(2):316–23. doi: 10.1097/00000542-199208000-00015. PubMed PMID: 1386498.

3. Cook DR, Brandom BW, Shiu G, Wolfson B. The inspired median effective dose, brain concentration at anesthesia, and cardiovascular index for halothane in young rats. AnesthAnalg. 1981;60(4):182–5.

4. Diaz JH. Halothane anesthesia in infancy: identification and correlation of preoperative risk factors with intraoperative arterial hypotension and postoperative recovery. J Pediatr Surg. 1985;20(5):502–7. doi: 10.1016/s0022-3468(85)80475-9. PubMed PMID: 4057016.

5. Friesen RH, Lichtor JL. Cardiovascular depression during halothane anesthesia in infants: study of three induction techniques. AnesthAnalg. 1982;61(1):42–5.

6. Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. AnesthAnalg. 1990;70(2):160–7.

7. Morray JP, Geiduschek JM, Ramamoorthy C, Haberkern CM, Hackel A, Caplan RA, et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology. 2000;93(1):6–14.

8. Holzman RS, van der Velde ME, Kaus SJ, Body SC, Colan SD, Sullivan LJ, et al. Sevoflurane depresses myocardial contractility less than halothane during induction of anesthesia in children. Anesthesiology. 1996;85(6):1260–7. doi: 10.1097/00000542-199612000-00006. PubMed PMID: 8968172.

9. Wodey E, Pladys P, Copin C, Lucas MM, Chaumont A, Carre P, et al. Comparative hemodynamic depression of sevoflurane versus halothane in infants: an echocardiographic study. Anesthesiology. 1997;87(4):795–800. doi: 10.1097/00000542-199710000-00012. PubMed PMID: 9357880.

Yes, I still attend live performances, but I’ve long given up on vinyl records and CDs, opting to simply listen to music over the internet. Are there advantages to older formats? Of course, and many of you who may be music afficionados may still prize vinyl, but in reality, technological advancement has changed how we listen to music. Similarly, how we intubate our patients is changing as well.

In today’s PAAD, Uchinami et al.(1) demonstrate once again a dramatic improvement in first-pass success seen with video laryngoscopy (VL) over direct laryngoscopy (DL) during infant intubation by inexperienced trainees. In the accompanying editorial, Rowland et al.(2) say what is increasingly obvious: “Now is the time to stop viewing VL as a crutch in infant intubation, but rather the solution to improved education, increased first-pass success, and likely reduction in complications.”

Additionally, I wonder if this evolution should be limited to newborns and infants while training students. Should we consider extending these findings to ALL patients and not limit it to the initial education of trainees? Myron Yaster MD

Editorial

Rowland MJ, Jagannathan M, Jackson S. We Can See Clearly Now That Video Is Here: Videolaryngoscopy in Infants. Anesth Analg. 2026 Jul 1;143(1):1-3. doi: 10.1213/ANE.0000000000008036. Epub 2026 Mar 23. PMID: 41874959.

Original article

Uchinami Y, Fujita N, Hoshino K, Kubo Y, Yagi Y, Shoji M, Yokota I, Morimoto Y. Effectiveness of McGRATH MAC Video Laryngoscopy for First-Attempt Intubation by Anesthesia Trainees in Infants: A Randomized Controlled Trial. Anesth Analg. 2026 Jul 1;143(1):5-15. doi: 10.1213/ANE.0000000000007952. Epub 2026 Feb 16. PMID: 41698200.

Newborn and infant airway management remains one of the most challenging skills in pediatric anesthesiology. Unique anatomical features including a relatively large tongue, cephalad larynx, and highly mobile epiglottis, combined with limited oxygen reserves make desaturation exceedingly common during neonatal intubation. This is true regardless of technique.(3) Further, because desaturation results in hypoxemia and bradycardia, first-pass success is critically important. (And please, please don’t forget routine preoxygenation and apneic oxygenation during intubation!)

Although VL has become increasingly available and previous studies such as the landmark multicenter RCT Video Laryngoscopy in Small Infants (VISI) trial (4) demonstrate improved first-attempt success in infants. Uncertainty remains regarding its effectiveness when used by novice practitioners. Uchinami et al. specifically sought to determine whether the McGRATH MAC video laryngoscope could improve first-attempt intubation success among anesthesia trainees.

(A size 1 blade was used for both McGrath VL and DL; for DL, either a Macintosh or a Miller blade was available. Note that there is no McGrath Miller 1 size blade available)

This single-center randomized controlled trial enrolled 124 infants younger than one year undergoing elective non-cardiac surgery requiring tracheal intubation. Patients were randomized to intubation with either a McGRATH MAC size 1 videolaryngoscope or conventional direct laryngoscopy using Macintosh or Miller blades (figure above). All intubations were performed by anesthesia trainees under direct supervision. The primary outcome was successful tracheal intubation on the first attempt. Secondary outcomes included glottic visualization, intubation difficulty, time to intubation, and peri-intubation complications. Twenty-seven trainees participated, ranging from first-year residents to more advanced trainees.

Ok, what did they find? Uchinami et al found a significant improvement in first-pass success with VL. First-attempt intubation was successful in 86.9% of infants in the VL group compared with 74.6% in the DL group, representing an absolute improvement of 16.5%. Additionally, perfect glottic visualization occurred in 60.7% of VL cases versus 36.5% with direct laryngoscopy and perhaps most importantly, esophageal intubation occurred only in the DL group (summarized in the journal’s infographic below).

Rowland et al in the accompanying editorial highlight that perhaps the most important observation of this study: VL appears particularly beneficial for novice providers. First-year anesthesia trainees achieved an 81.5% first-pass success rate with VL compared with only 51.9% using DL. By contrast, more experienced trainees demonstrated similarly high success rates with both techniques. However, they also point out what we have said before in previous PAADs: VL should not replace comprehensive airway education. Effective instruction still requires deliberate coaching, standardized feedback, and simulation-based practice. Furthermore, there are some circumstances in which DL skills remain necessary: indirect device failure, lack of access to indirect devices, and perhaps camera failure from blood or bodily fluids. Consequently, VL should be viewed as an educational platform rather than an absolute substitute for fundamental airway management skills. One interesting aspect to this study was the choice of laryngoscope used. Many pediatric anesthesiologists avoid the McGrath system for infant intubation because of the blade’s size and shape (thicker and wider in all dimensions at the distal part of the phlange), and instead prefer a Miller 0 or 1 blade. This study challenges those preconceptions, and further emphasizes the superiority of indirect video laryngoscopy for tracheal intubation in infants.

We think that routine VL use can enhance patient safety, improve training effectiveness, reduce esophageal intubation, and facilitate the acquisition of airway skills – particularly for our youngest patients. We challenge our readership to consider: should we ALL make the switch to routine VL while intubating all patients? While this is a view not supported by most of you(5), we wonder if it is time to study that very question to know which population(s) benefit from a switch from DL to VL. One final important thought: not all videolaryngoscopes are created equal! A MAC-style blade in this brand of device may not allow enough mouth space in neonates to intubate (although this study casts doubt on that), and hyperangulated blades may provide a better view but not necessarily easier intubation. Indeed, there are video devices that are the same thickness, shape and weight as a traditional MAC or Miller DL blade – perhaps those are the “best.”

With all of this new information becoming available to make the care of our patients better, we want to hear your thoughts! Send your comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Uchinami Y, Fujita N, Hoshino K, Kubo Y, Yagi Y, Shoji M, et al. Effectiveness of McGRATH MAC Video Laryngoscopy for First-Attempt Intubation by Anesthesia Trainees in Infants: A Randomized Controlled Trial. Anesthesia and analgesia. 2026;143(1):5–15. Epub 20260216. doi: 10.1213/ane.0000000000007952. PubMed PMID: 41698200.

2. Rowland MJ, Jagannathan M, Jackson S. We Can See Clearly Now That Video Is Here: Videolaryngoscopy in Infants. Anesthesia and analgesia. 2026;143(1):1–3. Epub 20260323. doi: 10.1213/ane.0000000000008036. PubMed PMID: 41874959.

3. Kothari R, Hodgson KA, Davis PG, Thio M, Manley BJ, O’Currain E. Time to desaturation in preterm infants undergoing endotracheal intubation. Arch Dis Child Fetal Neonatal Ed. 2021;106(6):603–7. Epub 20210430. doi: 10.1136/archdischild-2020-319509. PubMed PMID: 33931396; PubMed Central PMCID: PMC8543201.

4. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, et al. First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet (London, England). 2020;396(10266):1905–13. Epub 2020/12/15. doi: 10.1016/s0140-6736(20)32532-0. PubMed PMID: 33308472.

5. Bai W, Koppera P, Yuan Y, Mentz G, Pearce B, Therrian M, et al. Availability and Practice Patterns of Videolaryngoscopy and Adaptation of Apneic Oxygenation in Pediatric Anesthesia: A Cross-Sectional Survey of Pediatric Anesthesiologists. Paediatric anaesthesia. 2025;35(6):460–8. Epub 20250205. doi: 10.1111/pan.15079. PubMed PMID: 39907265; PubMed Central PMCID: PMC12060081.

From Nancy Finnel

The U.S. Food and Drug Administration today licensed Ezplaz Freeze Dried Plasma (FDP), making it the first freeze-dried plasma product licensed for use in the United States. Ezplaz is intended for transfusion in adult patients who need plasma and for whom other plasma products are not available.

Traditional frozen plasma requires strict cold-chain management and a lengthy thawing process. EZPLAZ eliminates these barriers with the following operational features:

• Shelf Stability: It can be stored at room temperature (2°C to 25°C / 36°F to 77°F) for up to 12 months.

• Rapid Reconstitution: It mixes with 250 mL of Sterile Water for Injection (SWFI) in just 1 to 2.5 minutes.

• Durable Packaging: It is packaged in a flexible plastic bag instead of fragile glass vials, making it highly portable.

• Universal Applications: Formulated using blood group AB or low-titer Type A donor plasma, reducing the immediate need for a type-and-crossmatch screen

From Nancy Finnel

How Advanced Sutures Are Changing Wound Closure

https://www.medscape.com/viewarticle/how-advanced-sutures-are-changing-wound-closure-2026a1000sn1?ecd=a2a

Physicians have used sutures for more than 5000 years. And while they’ve evolved, from linen to silk and even old-school catgut (which is, of course, not made from cats but collagen fibers from bovines and sheep), doctors have been sewing with the same suture materials for decades. But in recent years, new advances in sutures have entered the market with the goal of doing far more than holding tissue together.

“A suture sits precisely at the tissue interface during the most biologically active and infection-vulnerable phase of healing — the first 1-2 weeks postoperatively,” said Christopher Homsy, MD, a plastic and reconstructive surgeon at Tufts Medical Center, Boston.

That window has inspired researchers to rethink what else a suture can accomplish. Some release antimicrobial or anti-inflammatory medications directly into the wound. Others are being designed to deliver local pain medications or growth factors directly into the surgical site. And more futuristic designs are poised to incorporate sensors capable of detecting changes in pH, temperature, or other biomarkers that could help doctors catch signs of infection or impaired healing before clinical symptoms appear.

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

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The August 2026 issue of Anesthesiology provided tributes to two giants of our specialty, a touching tribute to Dr. Larry Saidman by Dr. Steve Shafer,² and the Wood Library-Museum of Anesthesiology remembrance of Dr. Tom Hornbein by Dr.s Moon and Rathmell.³

Tom Hornbein (above) hired me to join his University of Washington, Seattle (UW) faculty in 1983 (no committee, no interviews, just an exec decision), and he was the most important, instructive and humble chair of my 4-decade career. Joining Hornbein’s department as a stripling anesthesiologist, I had no idea of Tom’s legendary status; it was not until more than five years in his department that I learned of his 20-year-old legendary feat. Tom, who is lesser known than Dr. Saidman, had an historic accomplishment touched upon in the Wood Library tribute but that deserves further elaboration.

Tom, an experienced and well-known mountaineer, was one of the climbers of the 1963 American Mount Everest Expedition, the first Americans to conquer Everest and the first climbers of any stripe since the New Zealander Sir Edmund Hillary’s 1953 feat, who was knighted for this accomplishment by Queen Elizabeth. The first American Expedition climbers to the summit were Jim Whittaker and sherpa Nawang Gombu, who climbed the same South Col route as Hillary ten years earlier. To this day it is Whittaker’s name that is remembered as the first American to summit Everest but less remembered are the names of two others on the Expedition whose accomplishment was far more significant and remarkable.

On May 22, 1963, three weeks after Whittaker planted the American flag on Everest, Tom Hornbein and his climbing partner and good friend Willi Unsoeld left the Expedition’s high camp to climb a much more technical and yet unmapped route, the West Ridge. This was considered to be unclimbable by mountaineers. And after climbing the West Ridge to the summit, they continued to traverse Everest by descending the South Col, therefore also the first climbers to accomplish that feat, one which has been repeated only fewer than a dozen times in the ensuing 6 decades.

Hornbein and Unsoeld arrived at the summit late in the day, 6:15 p.m., just two hours before sunset. After 20 minutes on the top of the world, knowing there was not a prayer of returning to camp that night they started their descent into the approaching darkness, on what was to be a black, moonless night. Two other climbers on the American Expedition, Lute Jerstad and Barry Bishop, had summitted earlier on that day via the South Col, enabling Hornbein and Unsold to use their footprints to pick the way down in the failing light. A few hours later they were in complete darkness, their flashlights with dead batteries, descending into blackness. Separated by only five feet of rope they were invisible to each other.

Three hours into their descent they encountered Jerstad and Bishop, who were exhausted and out of oxygen. Together the four continued, but soon Hornbein’s oxygen was also gone. It had taken three hours to descend only 400 feet, a 15-minute effort in daylight. At that point the four had no choice but to bivouac or die in a fall. On an outcrop of rock without oxygen, tent, food or sleeping bags, they spent the remainder of the night above 28,000 feet in -18°F weather. Against the odds, the four survived, largely, Tom told me, because it was an uncharacteristically windless night. But Bishop’s and Unsoeld’s feet were badly frostbitten, and Tom told me he believed his cognitive abilities were never the same since that hypoxic night. If that was true, it is all the more remarkable because in my career I met few more brilliant or as scientifically intuitive as Tom. Later, he described the climb and the relationship of motivation vs. success in the book, Everest: The West Ridge.⁴

So remarkable was this accomplishment that a couloir (in English, col) on the West Ridge was named the “Hornbein Couloir.” By whom it was named is not known. The Wikipedia entry states that Hornbein named it, something that could not possibly be true. The historian of the American Alpine Society and editor in chief of its journal told me that he thinks that Unsoeld or another of the Expedition named it after Tom. The Swiss author, film maker and expert on the history of mountaineering, Jochen Hemmleb, wrote me that “Unsoeld addressed the feature as “Hornbein’s Couloir” first, and the name has stuck ever since. I have never seen an earlier reference.”

The Col is a narrow and steep passage to the west of the north face of Everest at about 26,000 feet elevation. The first half rises at a challenging 47° pitch, and the last segment, narrower and steeper, at a truly remarkable 60°. In his book, Into Thin Air, Jon Krakauer writes that “Hornbein’s and Unsoeld’s ascent was deservedly hailed as one of the great feats in the annals of mountaineering,” and is regarded by mountaineers as a greater accomplishment than Jim Whittaker’s.⁵

Steven Shafer’s tribute to Lawrence “Larry” Saidman chronicles the career and enduring influence of a transformative anesthesiologist, investigator, editor, and mentor. Saidman helped establish minimum alveolar concentration (MAC) as the standard measure of inhaled anesthetic potency and contributed to seminal investigations of anesthetic pharmacology and malignant hyperthermia. As Chair at UCSD and Editor-in-Chief of Anesthesiology, he advanced clinical pharmacology, scientific rigor, and generations of academic anesthesiologists. Shafer emphasizes Saidman’s extraordinary mentorship, integrity, generosity, and humanity. His legacy extends beyond scientific discovery and editorial leadership to the clinicians, investigators, patients, and specialty he profoundly influenced.

There is little more to say about Larry Saidman that wasn’t said by Dr. Shafer. But I do have a telling anecdote to share: Tom Hornbein and Larry Saidman were good friends, and both had animus towards the commercialization of medicine and the pernicious influence of pharmaceutical giveaways, lunches, trips, “lectures,” and even the chocolates, mints, pens, and tote bags given away at ASA meetings by vendors. One year, Tom saw Larry (or the other way around, I don’t remember) carrying such a tote bag at an ASA meeting and chastised him for the transgression. The transgressor explained he had left his backpack at his hotel but needed something in which to carry the program, abstracts, and other stuff; accepting a bag at a commercial exhibit he turned it inside out to conceal the company’s promotion. In this and other ways they were both of solid and uncompromising principles. They are both missed by all who knew them and whose lives were touched by them.

References

1. Krane, EJ: A further note on Dr. Hornbein and Dr. Saidman (letter). Anesthesiology 2026, in print

2. Shafer, SL: Thank you, Larry Saidman. Anesthesiology 2026; 145:288-290. doi: 10.1097/ALN.0000000000006132

3. Anesthesiology Reflections From The Wood Library-Museum: Tom Hornbein, M.D.: The Willingness to Risk. Anesthesiology 2026; 145:372. doi: 10.1097/ALN.0000000000006212

4. Hornbein, T: Everest: The West Ridge. San Francisco, The Sierra Club, 1965. Republished: 1980, Seattle, The Mountaineers

5. Krakauer, Jon: Into Thin Air: A Personal Account of the Mt. Everest Disaster. New York, Anchor Books/Doubleday, 1999

Thanks for highlighting our article in the PAAD here on perioperative blood transfusion in neonates.

The link to the podcast we did with the section editor Shannon Farmer is below. He asked a lot of interesting questions and my neonatal intensivist co-author; Patricia Davenport and I had fun answering them.

https://journals.lww.com/anesthesia-analgesia/podcasts/3

I always preach to “treat the patient not the number” and that “less is more”.

Our results suggest the harmful effects of over transfusion and one mechanism that the editorial points is that transfusion of adult RBC’s may induce tissue hyperemia and oxidative stress by Hb A to displacing Hb F.

Patient blood management is centered around increasing the patients own individual Blood Health and in our vulnerable neonatal population using physiological tools to guide decisions to transfuse or not to transfuse should be the focus of future care and research.

From Roberto Velasco, MSN, RN, CCRN, CFRN, NREMT, C-NPT, Registered Nurse | Transport Team, Seattle Children’s on capnography during intrahospital transport here

Firstly, thank you for the awesomeness that is the PAAD! As a non-anesthesia provider, I find the content to be useful and enlightening for my position alongside my other continuing education.

I often wonder why some of the standards for patient care differ inside and outside of the walls of the hospital (and vice versa). In many transport programs, patients with an advanced airway must be monitored via continuous waveform capnography. GAMUT (Ground & Air Medical Quality in Transport) serves as a database of key metrics and performance for transport teams, which utilizes percentage of continuous waveform capnography usage for all patients with artificial airways as one of their tracked metrics and as a benchmark for the quality of care provided.

Current data for our program shows a capnography use percentage of over 94% across several years with an additional percentage of patients being monitored via transcutaneous CO2 monitoring whilst being transported on high frequency ventilation. While our patients are most certainly being transported for longer periods of time (decreasing the “cost per minute” of use), I’d argue that the potential of this monitoring to catch changes in the airway status/patient condition is even greater in the immediate perioperative period!

Thank you for all that you do,

From Dheeraj Nagpal, MD, Assistant Professor at NYP/Columbia University Medical Center, New York.

I agree with your statement, capnography is more important than other monitors if I have to choose, reason being in a patient who is adequately ventilated, a capnograph showing regular breathing is the best option to confirm adequate status.

We all have transported sedated patients across tunnels and bridges as “BigMAC is the flavor of the century “: I think capnography during transport should be utilized more to ensure a stable patient. Lastly, we should consider wide use of transcutaneous capnography.

From Ruchik Sharma, MD, University of Virginia on perioperative blood transfusion in neonates.

After reading today’s PAAD I have several questions:

1. Are the NICU neonates managed differently than PICU neonates? Asking because most freestanding Children’s Hospitals have the NICU physically separate(mom and child), and most CDH, TEF, surgical neonate is housed in the PICU. Is this accurate, for the purpose of this study?

2. The neonate is a category where PRBCs are given for hemodynamic instability...rheologic support of BP, or in anticipation of bleeding. Overtransfusion and undertransfusion leads to cardiac arrest from hyperkalemia, and hypovolemia resp. And typically, NICU access is a neoPICC, with a 24G PIV if lucky.

3. Intra-op hemodynamics were not mentioned, and so, the indication of blood transfusion is not clear. Active bleeding, anticipated bleeding, poor physiologic reserve, poor intraop physiology.

4. Boston anesthesia, or Boston NICU has an internal database for Patient Blood Management. Would love to see that Case Report Form, I didn’t see it in the supplement. This probably has some nuanced reasoning for transfusion.

   PS: UVA's NICU and PICU are on the same floor( most mixed adult-peds hospitals will have this advantage), and we have surgical teams rounding on there request transfusion for babies on a surgical-watch. Also, because of PICU-NICU proximity, NIRS use is common both places, although much more in PICU/PCICU.

We’ve recently discussed a similar study by McCormack et al. (2) which was based on a large database study of the American College of Surgeons National Surgical Quality Improvement Program’s (NSQIP) registry. And the results of today’s study by Hart et al. are very similar. But before we begin today’s PAAD, I thought it would be worth a moment to review how anemia is defined in these studies. I (M.Y used AI, OpenEvidence for these definitions here and I am directly quoting from the OpenEvidence download below.

“The 2024 WHO update primarily revised the hemoglobin thresholds for young children aged 6–23 months (lowering the cutoff) and introduced a new altitude adjustment method, while largely maintaining the longstanding thresholds for older children and adults. The key evidence base for these changes came from the landmark Braat et al. analysis published in The Lancet Haematology (2024),(3) which pooled international data to estimate the 5th centile of hemoglobin in healthy reference populations.

The most clinically meaningful change was the lowered threshold for children aged 6–23 months from <11.0 g/dL to <10.5 g/dL, based on the Braat et al. pooled analysis showing the 5th centile of hemoglobin in healthy children aged 6–23 months was 10.4 g/dL (104.4 g/L).”

Obviously, the only way to accurately and definitely diagnosis anemia is by laboratory testing and in the United States, routine preoperative hemoglobin laboratory testing is thought to be unnecessary(4-6) except in those patients undergoing high risk surgical procedures or in patients with significant co-morbidities. Of note a recent publication in BJA the South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2) trial used Hemicue to successfully screen children in South African middle income setting.(7) Considering the importance of preoperative anemia in patient blood management programs (PBM) here and here and in the associated adverse patient centered outcomes described in today’s PAAD, should we reconsider these policies? Myron Yaster MD

Original article

Hart M, Batinic A, Skowno J. Preoperative Anemia and Perioperative Outcomes in Children: Prevalence, Risk Factors, and Associations in an Australian Cohort. Paediatr Anaesth. 2026 Jun 13. doi: 10.1002/pan.70236. Epub ahead of print. PMID: 42287094.

In today’s PAAD, Hart et al. conducted a retrospective observational cohort study of children aged 6 months to 18 years who underwent major surgery between January and December 2023. Patients were deemed eligible if they had a hemoglobin measurement within three months prior to surgery. Anemia was defined according to the updated 2024 World Health Organization (WHO) age- and sex-specific hemoglobin thresholds (see above). Clinical characteristics, transfusion requirements, and postoperative outcomes were analyzed using multivariable logistic regression.

Figure 1 (Study Flow Diagram) demonstrated patient selection. Of 786 eligible children undergoing major surgery, 609 had preoperative hemoglobin measurements. Thus, 177 patients or 22% were excluded before any attempt at analysis. Additionally, patients undergoing repeat surgery (n=23) and those recently transfused (n=4) were also excluded. Thus, in the final analysis only 582 patients remained, including 459 non-anemic and 123 anemic children (21%). Nearly half of anemic patients had mild anemia (48.8%), while 49.6% had moderate anemia and 1.6% had severe anemia.

Higher rates of anemia were identified in the following patient groups: Female sex, higher ASA physical status, surgical emergencies, solid organ malignancy, and chronic kidney disease. The surgical specialties with the highest anemia rates were gastroenterology, ENT, and general surgery.

The most important findings in this study was the impact of anemia on adverse postoperative outcomes. Perhaps not surprisingly, children with anemia were significantly more likely to receive red blood cell transfusions even after adjusting for cofounders: 53.7% of anemic patients received transfusions compared to 32.7% of non-anemic patients who received transfusions. Most surprisingly to us, postoperative infections requiring antibiotic therapy occurred more frequently in anemic patients: 32.5% in anemic children compared to 19.0% in non-anemic children. Indeed, preoperative anemia independently increased the odds of postoperative infection by nearly 90% (aOR 1.89; 95% CI 1.15–3.09; p=0.012). This as independent of a receiving a blood transfusion.

The study found no statistically significant association between preoperative anemia and: thromboembolic events, acute renal failure, length of hospital stay, survival to discharge, and 30-day mortality. However, the authors note that the study may have been underpowered to detect differences in these relatively uncommon outcomes.

So what are the clinical implications? Timely knowledge that a child is anemic preoperatively would be the first step in pediatric patient blood management (PBM). These anemic patients could be started on oral or even IV iron possibly together with Erythropoiesis-stimulating agents (ESAs), like epoetin alfa or darbepoetin alfa weeks before surgery. Both today’s article by Hart et al and the article by McCormack et al. reported anemia rates in children undergoing major surgery—21% and 25%, respectively—that are higher than the prevalence we would expect in our usual surgical patients. Why? The reason is patient selection. Only patients who had a preoperative hemoglobin measurements were included and those were pateints undergoing major surgery. Therefore, the lower risk patients were excluded. Nevertheless, the implications are clear, especially for those undergoing major surgery: preoperative anemia is independently associated with both perioperative transfusion and postoperative infection. Additionally, the authors point out that “allogeneic blood product transfusion also is associated with an increase postoperative infection risk through mechanisms such as transfusion-related immunomodulation. Since preoperative anemia is also correlated with transfusion and postoperative infection, it isnot possible to determine relative risk or causality. . Nevertheless, the results support increased attention to timely anemia screening and optimization as part of pediatric patient blood management initiatives in patients undergoing major surgery. As anesthesiologists cancel patients for NPO violations or recent URIs, perhaps we should require preoperative hemoglobins prior to major surgery and postpone to optimize? Optimization should harness the power of the child’s own blood health, replacing Iron if IDA is the etiology, stimulating erythropoiesis and/or medically managing anemia sue to other causes. Future prospective studies are really needed to determine whether targeted interventions can reduce transfusion exposure, postoperative complications, and healthcare costs in pediatric surgical populations.

What do you think? Are you reconsidering the need for preoperative hemoglobin levels in patients undergoing major surgery or with high risk factors? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Hart M, Batinic A, Skowno J. Preoperative Anemia and Perioperative Outcomes in Children: Prevalence, Risk Factors, and Associations in an Australian Cohort. Paediatric anaesthesia. 2026. Epub 20260613. doi: 10.1002/pan.70236. PubMed PMID: 42287094.

2. McCormack G, Faraoni D, DiNardo JA, Goobie SM. Association between preoperative anaemia, transfusion, and outcomes in children undergoing noncardiac surgery. British journal of anaesthesia. 2025;135(2):375–81. Epub 20250610. doi: 10.1016/j.bja.2025.04.050. PubMed PMID: 40500601.

3. Braat S, Fielding KL, Han J, Jackson VE, Zaloumis S, Xu JXH, et al. Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources. Lancet Haematol. 2024;11(4):e253–e64. Epub 20240229. doi: 10.1016/s2352-3026(24)00030-9. PubMed PMID: 38432242; PubMed Central PMCID: PMC10983828.

4. Roy WL, Lerman J, McIntyre BG. Preoperative hemoglobin values in minor paediatric surgery. CanJAnaesth. 1990;37(4 Pt 2):S7.

5. Hackmann T, Steward DJ, Sheps SB. Anemia in pediatric day-surgery patients: prevalence and detection. Anesthesiology. 1991;75(1):27–31.

6. Steward DJ. Screening tests before surgery in children [editorial; comment]. CanJAnaesth. 1991;38(6):693–5.

7. Meyer HM, Torborg A, Biccard B, Kluyts H, Louw VJ, Cox S, et al. South African Paediatric Surgical Outcomes Study-2 (SAPSOS-2): a prospective multi-centre pre-post study evaluating haemoglobin response to oral iron for iron-deficiency anaemia in children undergoing elective noncardiac surgery. British journal of anaesthesia. 2026. Epub 20260701. doi: 10.1016/j.bja.2026.06.001. PubMed PMID: 42386436.

From a previous reader response: “There’s no question that pulse oximetry is a valuable monitoring tool in any clinical situation associated with hypoxemia. As such, changes in SpO2 are a sensitive indicator of disease severity and response to treatment in conditions associated with ventilation/perfusion mismatch and intrapulmonary or intracardiac shunt, such as asthma, bronchopulmonary dysplasia, bronchiolitis, pneumonia, and congenital heart disease. However, conditions associated with hypercarbia due to reduced alveolar ventilation (hypoventilation) as a result of partial airway obstruction or depression of ventilation (endotracheal tube kinking or disconnect, ventilator failure, drugs) will not be associated with significant changes in SpO2, particularly if supplemental oxygen is administered, until partial pressure of carbon dioxide in arterial blood is extremely elevated. Hence, use of pulse oximetry could result in a delay of diagnosis in these conditions – especially in the PACU or PICU or in sedated patients in whom oxygen supplementation is standard practice. Moreover, there is only one monitor that we use than can singlehandedly provide data about all 3 of the ABCs: Capnography. If any one of airway, breathing, or circulation are not intact, there is a change (or loss) of EtCO2.” (Justin L. Lockman MD MSEd)

In today’s PAAD, researchers at the Boston Children’s Hospital(1) using a quality improvement (QI) initiative, instituted the mandatory use of capnography in intrahospital transport of mechanically ventilated pediatric patients with congenital heart disease (CHD). They describe how their multidisciplinary QI team, consisting of pediatric cardiac anesthesiologists and anesthesia technicians, implemented the initiative using multiple Plan–Do–Study–Act (PDSA) cycles in accordance with the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines. The senior authors, Drs. Jim DiNardo and Viviane Nasr, are members of the PAAD’s executive council and are frequent contributors to the PAAD. Myron Yaster MD

Original article

Brown ML, Whiting D, DiNardo JA, Nasr VG. Institutional Experience Introducing Portable Capnography Intrahospital Transport of Ventilated Patients With Congenital Heart Disease. Anesth Analg. 2026 Aug 1;143(2):421-423. doi: 10.1213/ANE.0000000000007940. Epub 2026 Jan 14. PMID: 41534096.

Intrahospital transport of mechanically ventilated pediatric patients with congenital heart disease (CHD) is a high-risk process associated with significant respiratory and hemodynamic instability.(2) (see previous PAAD here ) In this QI study, Brown et al. describe the successful introduction of portable capnography for intrahospital transport of ventilated pediatric cardiac patients at a high-volume tertiary referral center, demonstrating that systematic implementation can achieve improvements in monitoring compliance. The authors failed to state their SMART (Specific, Measurable, Attainable, Relevant, and Time-bound) aim or target for the improvement efforts. In Seattle we typically strive for >80% to achieve a reliable process. We call the improvements sustained when the improvements have been maintained for at least 12 consecutive time intervals (i.e., weeks, months). Do we stop there? What is standing in the way for high reliability? It is people, equipment availability, etc.? We (LDM and CM) pursue continuous improvements using additional Plan–Do–Study–Act (PDSA) cycles to reach >90%, then >95%, and even >98% compliance to achieve highly reliable systems state. At these levels, it truly becomes the culture, ‘the way things are done around here’.

The authors identified the absence of end-tidal CO₂ (EtCO₂) monitoring during transport as an institutional practice gap. As you all know and as discussed in Myron’s introduction, capnography provides continuous, noninvasive assessment of ventilation, pulmonary perfusion, and metabolism while confirming endotracheal tube position and detecting ventilation-related complications. A multidisciplinary QI team consisting of pediatric cardiac anesthesiologists and anesthesia technicians implemented the initiative using multiple PDSA cycles in accordance with the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines. Educational sessions, equipment evaluation, workflow redesign, electronic medical record documentation, and iterative process refinement were incorporated throughout implementation. Figure 1 from the article illustrates the progressive introduction of the technology, including equipment selection, staff education, workflow integration, relocation of monitors, and subsequent equipment modifications to improve availability and reduce device loss.

Brown et al. reviewed all intubated CHD patients transported by the anesthesia service between January 2022 and May 2024. During the study period, 2,996 mechanically ventilated patients underwent intrahospital transport, with complete monitoring data available for 96% of transports. The median patient age was one year, and nearly half of the cohort consisted of neonates younger than 30 days, emphasizing the high-risk nature of the population. Approximately three-quarters of transports originated in the operating room, with the remainder occurring after cardiac catheterization or advanced cardiac imaging.

The initiative resulted in improvement >80% in capnography uses for the last 6 months. During the final three months of observation, monitoring compliance reached 86.3%, 80.7%, and 87.6%, demonstrating reliable adoption across the anesthesia service. Figure 2 from the article is an XmR (Mean and moving Range) Control chart which illustrates progressive improvement in compliance over successive implementation cycles.

The use of Statical Process Control (SPC) methods and control charts with their control limits is a significant step forward in understanding process change over the more typically used run chart. (3) Control charts allow users to distinguish between common cause (random) and special cause variation (SCV). There are well established rules use to define SCV as part of SPC methods. In quality improvement initiatives, the team is looking for SCV on the charts. Below I (LDM) have modified their original figure 2 to indicate at target of 80% compliance and identified two SCV signals on their chart. The first SCV (six consecutive increasing points) occurs with the introduction of the capnometers. The second SCV (eight or more consecutive point above the mean) occurred after the locking of monitors. Using SPC methods, this chart should have three separate cohorts (broken at the arrows) each with unique means and control limits. Note: There appears to be no SCV signal in the moving range (variability) chart if the highlighted point is on the mean as it appears.

Using the departmental event self-reporting system, only two transport-related adverse events or near misses occurred during the study period, neither of which was attributable to the capnography device itself. Instead, both events were associated with physiologic changes occurring during transition from mechanical ventilation to manual ventilation. Although the study was not powered to demonstrate improved clinical outcomes, these findings suggest that portable capnography can be integrated safely into routine transport without introducing additional risk. One can speculate if more adverse events would have been identified with ‘button tags’ (i.e., code, CPR, etc.), ‘trigger medication’ (i.e., epinephrine, etc.), or other sources of information (i.e., handoff reports) for additional adverse events, enhancing the ‘believability’ of this balance measure.

Implementation was associated with additional financial considerations. The acquisition cost was approximately US$2,087 per monitor, with disposable adapters costing US$10–16 per patient, resulting in estimated disposable expenditures of US$24,000–47,000 during the study period. However, reuse of disposable adapters by the intensive care unit frequently reduced overall institutional costs. The authors identified equipment availability and cost as the principal barriers to universal implementation.

This is a very reasonable fix to a common problem. However, we wonder why universal capnography monitoring should be limited to the intrahospital transport of only INTUBATED CHD patients? Why not use capnography in ALL intubated patients? This could be the next phase of their continuous improvement efforts enhancing safety. The final and most difficult task would be to use capnography in all intubated and non-intubated patients during transpotrt (think PACU)? Airway obstruction is common during transport of many of our patients. You’ve all experienced this in transport of non-intubated, semi-or unconscious patients to the PACU. Indeed, Dr. Peter Safar, widely recognized as the father of CPR, revolutionized emergency medicine by discovering that in unconscious humans, flexing the neck caused airway obstruction due to relaxed soft tissues and the tongue naturally falling backward. His landmark research in the 1950-60s established the foundational ABC’s of resuscitation. Technical limits in non-intubated patients and costs escalate with this last step and could represent ‘a bridge too far’.

How do you monitor intubated and non-intubated patients during intrahospital transport? Do you routinely use pulse oximetry? Capnography? ECG? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response

References

1. Brown ML, Whiting D, DiNardo JA, Nasr VG. Institutional Experience Introducing Portable Capnography Intrahospital Transport of Ventilated Patients With Congenital Heart Disease. Anesthesia and analgesia. 2026;143(2):421–3. Epub 20260114. doi: 10.1213/ane.0000000000007940. PubMed PMID: 41534096.

2. Haydar B. Error Traps in the Intrahospital Transport of Critically Ill and Anesthetized Children. Paediatric anaesthesia. 2025;35(7):497–503. Epub 20250408. doi: 10.1111/pan.15112. PubMed PMID: 40198097; PubMed Central PMCID: PMC12149488.

3. Provost LP, Murray SK. The Health Care Data Guide: Learning from Data for Improvement (John Wiley and Sons; Hoboken, NJ, 2022).

What are some common cognitive errors? Stiegler et al.(2) identify 14 including: anchoring (focusing on one issue at the expense of understanding the whole situation), availability bias (choosing a diagnosis because it is in the forefront of your mind due to an emotionally charged memory of a bad experience,) confirmation bias (seeking or acknowledging only information that confirms the desired or suspected diagnosis), premature closure (accepting a diagnosis prematurely, failure to consider reasonable differential of possibilities), overconfidence bias (inappropriate boldness, not recognizing the need for help, tendency to believe we are infallible), framing effect (subsequent thinking is swayed by leading aspects of initial presentation), commission bias (tendency toward action rather than inaction, performing maneuvers that are not indicated, deviating from protocol—may be due to overconfidence, desperation, or pressure from others), to name just a few. For a deeper dive into the science of error traps see the classic articles by Reason(3) and Dekker(4).

We think this is a terrific review article and for those of you who teach in the ORs, today’s PAAD is a great resource to distribute to your learners. After all, the use of neuromuscular blocking agents is among the most frequently used drugs in pediatric anesthesia and just about everyone who provides anesthesia to children can learn something about how to use them better. Myron Yaster MD

Original article

de Sousa GS, Faulk D, Quintao VC, Abbasian N, de Boer HD, Carlos RV. Error Traps in Pediatric Neuromuscular Block. Paediatr Anaesth. 2026 Aug;36(8):887-898. doi: 10.1002/pan.70202. Epub 2026 Apr 30. PMID: 42059407; PMCID: PMC13341026.

Neuromuscular blocking agents (NMBAs) are fundamental and indispensable in modern pediatric anesthesia, facilitating tracheal intubation, controlled ventilation, and optimal surgical conditions. However, inappropriate administration, inadequate monitoring, incomplete reversal, and failure to recognize residual neuromuscular block (RNMB) remain important and preventable causes of perioperative morbidity. This educational review by Sousa et al. identifies four major “error traps” that occur throughout the perioperative continuum and provides practical recommendations to improve patient safety (figure).(1)

The first error trap is failure to administer an NMBA when clinically indicated. Concern about losing spontaneous ventilation, particularly in infants or children with anticipated difficult airways, often leads clinicians to avoid NMBAs in almost all children. Current evidence suggests that this approach may paradoxically increase airway complications, including laryngospasm, bronchospasm, hypoxemia, and traumatic intubation. (5, 6) Adequately dosed intermediate-acting agents such as rocuronium or cisatracurium improve intubating conditions, reduce airway reflexes, and facilitate controlled ventilation while allowing lighter anesthetic depth and greater hemodynamic stability even in short surgical procedures. (7, 8) de Sousa et al. emphasize that withholding NMBAs when using controlled ventilation is appropriate should be viewed as a preventable safety error rather than a conservative strategy. However, if the decision is made not to use a NMBA for intubation (allergy, surgical contraindication to muscle relaxation or simply teaching intubation under spontaneous ventilation) deep anesthesia with high dose opioids, propofol, sevoflurane and other agents in different combinations is needed to obtain similar intubation conditions.

The second error trap is failure to objectively monitor neuromuscular blockade. Residual paralysis remains common in pediatric patients, with reported incidences approaching 30%–50% at extubation. Clinical signs—including spontaneous ventilation, limb movement, or head lift—and qualitative peripheral nerve stimulation are unreliable because they cannot detect clinically significant residual weakness when the train-of-four ratio (TOFR) ranges between 0.4 and 0.9.(9) Consequently, international guidelines now recommend routine quantitative monitoring using acceleromyography (AMG) or electromyography (EMG). EMG offers particular advantages in children because it remains accurate when the arms are tucked during surgery, is less affected by positioning than AMG, and is not affected by TOFR overshoot.(10, 11)

The third error trap involves inappropriate or mistimed pharmacologic reversal. Both neostigmine and sugammadex are effective only when used appropriately and guided by quantitative monitoring. Neostigmine should be administered only after partial spontaneous recovery (TOFR ≥0.4), as early administration may paradoxically prolong weakness and doses above 0.07 mg·kg⁻¹ provide little additional benefit while increasing muscarinic adverse effects.(6) Sugammadex provides rapid, predictable reversal of rocuronium- and vecuronium-induced blockade but is not infallible.(12) Underdosing, administration during profound block, altered infant pharmacokinetics, or renal impairment may result in recurrent paralysis.(13) Consequently, objective confirmation of recovery before extubation remains essential regardless of the reversal agent used.

The fourth error trap is failure to recognize and treat residual neuromuscular block in the post-anesthesia care unit (PACU). Even mild residual weakness impairs upper airway patency, ventilation, protective airway reflexes, and oxygenation, placing infants and young children at particular risk because of their limited physiological reserve. Postoperative agitation may mask residual weakness and lead to inappropriate administration of sedatives or opioids, further worsening respiratory compromise. High-risk patients, including infants, those with renal dysfunction, or patients receiving repeated NMBA dosing, require careful postoperative observation until complete neuromuscular recovery has been objectively confirmed. Finally, residual neuromuscular block rarely results from a single misstep but rather from the combined effect of insufficient intraoperative monitoring and suboptimal reversal practices.(12)

de Sousa et al. conclude that pediatric neuromuscular safety depends upon three overarching principles: routine quantitative monitoring throughout the perioperative period, individualized pharmacologic reversal based on objective assessment of block depth, and institutional policies that mandate standardized monitoring, education, simulation, and audit. The central recommendation is unequivocal: every child receiving an NMBA should demonstrate an objectively measured TOFR ≥0.9 before extubation or discharge from the operating room. I (FV) tested TOF stimulation on myself and it is quite painful so using it to reassess residual blockade in awake children in the PACU should only be performed if there any signs of muscular weakness.

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

References

1. de Sousa GS, Faulk D, Quintao VC, Abbasian N, de Boer HD, Carlos RV. Error Traps in Pediatric Neuromuscular Block. Paediatric anaesthesia. 2026;36(8):887–98. Epub 20260430. doi: 10.1002/pan.70202. PubMed PMID: 42059407; PubMed Central PMCID: PMC13341026.

2. Stiegler MP, Tung A. Cognitive processes in anesthesiology decision making. Anesthesiology. 2014;120(1):204–17. doi: 10.1097/aln.0000000000000073. PubMed PMID: 24212195.

3. Reason J. Human error: models and management. BMJ (Clinical research ed). 2000;320(7237):768–70. Epub 2000/03/17. doi: 10.1136/bmj.320.7237.768. PubMed PMID: 10720363; PubMed Central PMCID: PMC1117770.

4. Dekker SW. Reconstructing human contributions to accidents: the new view on error and performance. Journal of safety research. 2002;33(3):371–85. Epub 2002/10/31. doi: 10.1016/s0022-4375(02)00032-4. PubMed PMID: 12404999.

5. Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H, Patel V, Jagannathan N, Burjek N, et al. A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Anesthesia and analgesia. 2020;131(2):469–79. doi: 10.1213/ane.0000000000004393. PubMed PMID: 31567318.

6. Rodney G, Raju P, Brull SJ. Neuromuscular block management: evidence-based principles and practice. BJA Educ. 2024;24(1):13–22. Epub 20231129. doi: 10.1016/j.bjae.2023.10.005. PubMed PMID: 38495745; PubMed Central PMCID: PMC10941205.

7. Vanlinthout LE, Driessen JJ, Stolker RJ, Lesaffre EM, Berghmans JM, Staals LM. Effect of neuromuscular blocking agents on tracheal intubation quality in paediatric patients: a systematic review using network meta-analysis and meta-regression. British journal of anaesthesia. 2025;135(6):1787–802. Epub 20251010. doi: 10.1016/j.bja.2025.08.036. PubMed PMID: 41076411.

8. Park S, Kim JH, Bae JC, Lee JR, Kim MS. Tracheal intubation with or without a neuromuscular blocking agent for a short surgical procedure in children: Prospective, randomized, double-blind trial. Paediatric anaesthesia. 2021;31(8):863–70. Epub 20210603. doi: 10.1111/pan.14205. PubMed PMID: 33993571.

9. Ledowski T, O’Dea B, Meyerkort L, Hegarty M, von Ungern-Sternberg BS. Postoperative Residual Neuromuscular Paralysis at an Australian Tertiary Children’s Hospital. Anesthesiology research and practice. 2015;2015:410248. Epub 20150510. doi: 10.1155/2015/410248. PubMed PMID: 26064105; PubMed Central PMCID: PMC4441980.

10. Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023;138(1):13–41. doi: 10.1097/aln.0000000000004379. PubMed PMID: 36520073.

11. Veyckemans F, Debouche S, Kaufmann J, Disma N, Amigoni A, Bonatti G, et al. 2025 ESAIC and ESPA Guidelines on neuromuscular block in anaesthetised children: Indications, monitoring and reversal. European journal of anaesthesiology. 2026;43(4):295–323. Epub 20260304. doi: 10.1097/eja.0000000000002357. PubMed PMID: 41766420.

12. Cates AC, Freundlich RE, Clifton JC, Lorinc AN. Analysis of the factors contributing to residual weakness after sugammadex administration in pediatric patients under 2 years of age. Paediatric anaesthesia. 2023. Epub 20231004. doi: 10.1111/pan.14773. PubMed PMID: 37792601.

13. Salaün JP, Décary E, Veyckemans F. Recurarisation after sugammadex in children: review of case reports and recommendations. British journal of anaesthesia. 2024;132(2):410–4. Epub 20231028. doi: 10.1016/j.bja.2023.09.028. PubMed PMID: 38170632.

And you’ve all been in this spot when a newborn comes to the OR for emergency surgery. The hemoglobin is below 10, do you transfuse or not? And if you do and there is some left over blood, do you “top off the tank” and give what’s left in the bag rather than wasting it?

One final thought before you read today’s PAAD: The first author of today’s article, Dr. Susan Goobie, is the PAAD’s “go-to” expert on all issues related to pediatric patient blood management, so Lynne and I had to review this without her expertise. Myron Yaster MD

Original article

Goobie SM, Huang Q, Seshadri S, Kordun A, Staffa SJ, Davenport P, Sola-Visner M, Cravero J. Perioperative Blood Transfusion, Postoperative Hemoglobin, and Clinical Outcomes in Neonates: A Retrospective Observational Study From a Large Quaternary Hospital. Anesth Analg. 2026 Aug 1;143(2):221-230. doi: 10.1213/ANE.0000000000007825. Epub 2025 Nov 11. PMID: 41218025.

Editorial

Stevenson DK, Wong RJ, Chock VY, Pașca AM, Ahern TL. Red Blood Cell Transfusions: Evidence Favors a Restrictive Approach in Neonates. Anesth Analg. 2026 Aug 1;143(2):217-219. doi: 10.1213/ANE.0000000000008002. Epub 2026 Mar 2. PMID: 42385720.

“Neonates are one of the most frequently transfused groups in hospitals.”(1) Although perioperative data are limited, up to 90% of low-birth-weight neonates receive at least one red blood cell (RBC) transfusion during their hospitalization.(1, 3) International perioperative guidelines derived from randomized trials and expert consensus suggest maintaining neonatal hemoglobin (Hb) levels within the range of 7.5 to 12.0 g/dL, depending on gestational age, postnatal age, oxygen dependency, respiratory support, hemodynamic status, and comorbidities.(3, 4) This retrospective observational single center study (Boston Children’s Hospital) aimed to assess the rate of neonatal RBC transfusion and the prevalence of neonatal RBC over transfusion in noncardiac surgery.

Goobie et al analyzed 1,305 neonates undergoing noncardiac surgery between 2017 and 2023, of whom 297 (22.8%) received perioperative RBC transfusions. Among the 274 transfused neonates with postoperative Hb measurements, 51.1% achieved Hb concentrations ≥12 g/dL, a threshold the authors defined as “over transfusion” based on current neonatal transfusion recommendations advocating restrictive Hb targets between approximately 7.5 and 12 g/dL according to gestational age, respiratory support, and clinical status.(3, 4) Given the retrospective nature of the analysis, it is impossible to know the rationale of the anesthesia team’s decision to transfuse and how much volume to administer. Although the authors focus on preoperative Hb and putative transfusion targets, it is possible that blood was administered in order to treat hypotension in situations in which there might be hesitancy to give large volumes of crystalloid in infants who might develop adverse effects from excessive fluid administration, or in whom crystalloid and vasopressor administration may not have resulted in a desirable blood pressure. It is also impossible to know whether Hb was sequentially monitored in the operating room in order to inform the decision to stop giving blood at a designated target value.

Most transfused infants were critically ill: over half were premature, nearly three-quarters underwent emergency surgery, and almost two-thirds were anemic preoperatively. Younger neonates and those undergoing gastrointestinal surgery were more likely to have higher postoperative Hb levels. This may be related to blood rather than crystalloid administration for blood pressure support in these smaller, younger infants, as discussed above. Interestingly, severe preoperative anemia was associated with a lower likelihood of over transfusion, suggesting that transfusions in profoundly anemic infants were administered more appropriately.

A key finding was that postoperative Hb concentration itself was not associated with clinically important outcomes. Over transfusion did not increase hospital length of stay, neonatal intensive care unit (NICU) stay, postoperative morbidity, or mortality after multivariable adjustment. Rather than the achieved Hb level, the volume of blood transfused emerged as the clinically relevant determinant of outcome.

It should be noted that there is one error in the article’s text in the discussion of morbidity: “Major morbidities in the full cohort and the post-transfusion Hb cohorts are shown in Table 3 with a composite mortality incidence of 61.0%.” Looking at Table 3, it is clear that what is discussed is composite morbidity not mortality.

Neonates who died within 30 days received substantially larger transfusion volumes than survivors (median 41.0 versus 20.8 mL/kg). After adjustment for age, prematurity, weight, preoperative anemia, emergency surgery, and ASA physical status, each additional 5 mL/kg of RBC transfused increased the odds of 30-day mortality by approximately 5%. Receiver operating characteristic analyses identified perioperative transfusion volumes exceeding approximately 25 mL/kg as being associated with significantly increased 30-day and 1-year mortality. Although causality cannot be established in this retrospective study because sicker infants may require larger transfusions, these findings emphasize that transfusion volume may be a more meaningful quality metric than postoperative Hb concentration alone.

The accompanying editorial by Stevenson et al. extends these observations by questioning the traditional practice of using Hb concentration as the principal trigger for neonatal transfusion. This is a fantastic review of the oxygen delivery characteristics of fetal (Hb F) and adult (Hb A) hemoglobin and is a must read for all pediatric anesthesiologists. The authors emphasize that neonatal physiology differs fundamentally from that of older children and adults because Hb F predominates during early life. Hb F possesses a higher oxygen affinity than Hb A, facilitating oxygen transport while limiting tissue hyperoxia.(5) Adult donor RBCs containing Hb A may increase tissue oxygen delivery beyond metabolic requirements, potentially promoting oxidative stress and inflammatory injury in vulnerable premature infants. Indeed, for an even deeper dive, we would also highly recommend the on-line article by Timothy Ghan and Debnath Chatterjee “Oxygen Physiology” in OpenAnesthesia:

https://www.openanesthesia.org/keywords/oxygen-physiology/?search_term=fetal%20hemoglobin

This mechanistic framework may explain previous associations between transfusions and bronchopulmonary dysplasia, retinopathy of prematurity,(6) necrotizing enterocolitis, and neurodevelopmental injury.(2) The editorial also highlights additional potential contributors to transfusion-related harm, including transfusion-associated immunomodulation and donor-derived microparticles. Importantly, the authors argue that Hb concentration is an imperfect surrogate for tissue oxygen delivery and advocate future incorporation of physiologic markers such as near-infrared spectroscopy (NIRS)-derived tissue oxygenation into transfusion decision-making. This will be discussed in much greater detail in upcoming PAADs.

Collectively, these articles support contemporary neonatal patient blood management principles favoring restrictive transfusion practices, minimization of unnecessary donor exposure, delayed cord clamping, blood conservation, and individualized assessment of oxygen delivery rather than correction of Hb values alone. Although prospective studies are needed to establish optimal perioperative transfusion triggers, the available evidence suggests that avoiding excessive transfusion volumes may improve outcomes in this highly vulnerable surgical population.

Thus, one of the key take home messages is that over transfusion is common during the perioperative period in neonates and is potentially dangerous. So “don’t top off the tank”! Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Goobie SM, Huang Q, Seshadri S, Kordun A, Staffa SJ, Davenport P, et al. Perioperative Blood Transfusion, Postoperative Hemoglobin, and Clinical Outcomes in Neonates: A Retrospective Observational Study From a Large Quaternary Hospital. Anesthesia and analgesia. 2026;143(2):221–30. Epub 20251111. doi: 10.1213/ane.0000000000007825. PubMed PMID: 41218025.

2. Stevenson DK, Wong RJ, Chock VY, Pașca AM, Ahern TL. Red Blood Cell Transfusions: Evidence Favors a Restrictive Approach in Neonates. Anesthesia and analgesia. 2026;143(2):217–9. Epub 20260302. doi: 10.1213/ane.0000000000008002. PubMed PMID: 42385720.

3. Villeneuve A, Arsenault V, Lacroix J, Tucci M. Neonatal red blood cell transfusion. Vox Sang. 2021;116(4):366–78. Epub 20201127. doi: 10.1111/vox.13036. PubMed PMID: 33245826.

4. Del Vecchio A, Franco C, Petrillo F, D’Amato G. Neonatal Transfusion Practice: When do Neonates Need Red Blood Cells or Platelets? Am J Perinatol. 2016;33(11):1079–84. Epub 20160907. doi: 10.1055/s-0036-1586106. PubMed PMID: 27603540.

5. Benesch RE, Maeda N, Benesch R. 2,3-Diphosphoglycerate and the relative affinity of adult and fetal hemoglobin for oxygen and carbon monoxide. Biochim Biophys Acta. 1972;257(1):178–82. doi: 10.1016/0005-2795(72)90268-1. PubMed PMID: 5009828.

6. Lust C, Vesoulis Z, Jackups R, Jr., Liao S, Rao R, Mathur AM. Early red cell transfusion is associated with development of severe retinopathy of prematurity. Journal of perinatology : official journal of the California Perinatal Association. 2019;39(3):393–400. Epub 20181120. doi: 10.1038/s41372-018-0274-9. PubMed PMID: 30459388; PubMed Central PMCID: PMC6391181.

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.

New Anaphylm sublingual epinephrine data address FDA’s concerns

Anaphylm (dibutepinephrine) is an investigational, needle-free sublingual film developed by Aquestive Therapeutics designed to treat severe allergic reactions and anaphylaxis. Roughly the size of a postage stamp, it dissolves under the tongue within seconds without water or swallowing

Key Features

• Format: Orally administered sublingual film.

• Packaging: Slim foil pouch smaller than a credit card, pocket-portable.

• Mechanism: Delivers a rapid surge of epinephrine through oral mucous membranes

  Key Data Addressing FDA Concerns

  The initial FDA rejection centered strictly on user errors during administration—such as tearing the film, chewing it, or placing it on top of the tongue—rather than safety or manufacturing flaws. The new data from Aquestive Therapeutics demonstrate that revised packaging and instructions have resolved these human factors issues:

  Pouch-Opening Speed: Median time to open the foil pouch plummeted from 17 seconds to just 3 seconds.

  Placement Accuracy: Incorrect film placement under the tongue was slashed by over 80%.

  Zero Chewing Events: Updated instructions eliminated instances of participants chewing or early-removing the film.

  Robust Absorption: Self-administered film delivered PK exposure comparable to clinician-administered dosing, achieving a fast median time to peak concentration (Tmax) of 12 minutes.

  Survey request from Joseph Sisk, MD, FAAP Project Lead, SPA-QS Associate Professor for SPA members

  This voluntary survey is for SPA members only. This is a request to complete the survey if you have not already done so (a Big Thank you if you have already filled it). The SPA- QS NPO work group deeply appreciates your time in completing this survey. The details of the survey and link are below.

  “Anesthesiologists practicing in the United States have largely adopted the 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. These guidelines were aimed to minimize the risk of anesthesia-related complications such as pulmonary aspiration in healthy patients undergoing elective procedures. Although the current nil per os (NPO) guidelines are intended to be comprehensive, many clinical situations specific to the pediatric population are left ambiguous. To address challenging situations not addressed in the ASA guidelines, the Society for Pediatric Anesthesia Quality and Safety Committee has formed the NPO Guidelines workgroup. The goal of this workgroup is to identify appropriate NPO times for common clinical scenarios.

  While we endeavor to use published evidence wherever possible, it is clear that not all NPO practices can be supported by existing literature. As such, this workgroup has developed a survey to assess the practices of current SPA members when confronted with ambiguous clinical guidelines.

  This is a research survey. The results will be included in a review article addressing common NPO concerns. Being a participant in this study may not immediately help or provide benefit to you, however with your participation we hope to improve the care of pediatric patients. There is no remuneration provided for participation in this study. By completing this survey, you are giving your consent to participate in the research study as described above. This survey is voluntary. All research includes the risk of breach of confidentiality. To mitigate this risk, no identifying information is required to complete the survey, and none will be collected.

  This survey consists of 28 clinical questions and 10 demographic questions. It should take approximately 10-15 minutes to complete. There will be an opportunity to leave comments at the end.”

  Please access the survey by clicking the link below or using the QR code:

  Survey Link: https://unc.az1.qualtrics.com/jfe/form/SV_8jC1OUU5cOW8tLM

  

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