April 2026

Paediatric anaesthesia

Submitted February 2026 by Dr Liam O'Doherty

Summary

Weba et al conducted this meta-analysis of 14 randomised controlled trials (RCTs) to evaluate the impact of topical lidocaine on perioperative respiratory events (PRAEs) in children undergoing airway management.

The purpose of the study was to include more recently published RCTs given the heterogeneity in study outcomes with topical lidocaine.

Fourteen RCTs were identified including 1937 paediatric patients, of whom 917 (47%) received airway topicalization with lidocaine. Studies were appropriately selected for the stated aims. The included studies had patient populations between 20 and 322 patients.

In those receiving topical lidocaine there was a significant reduction in the incidence of laryngospasm, desaturation and sore throat. There was no significant difference observed for bronchospasm, cough, severe cough, hoarseness, vomiting and heart rate.

Airway procedures included endotracheal intubation, laryngeal mask insertion and bronchoscopy. Lidocaine airway intervention treatments included 0.5%, 1%, 2%, 4% and 6.5% formulations in gel, cream, nebulisation and endotracheal tube cuff injection. Control group treatments included nebulised saline, saline spray, IV lignocaine plus intracuff saline, K-Y jelly, placebo drug and placebo gel.

Sub-group analyses were performed based on the following groups: lidocaine formulation type, airway intervention (endotracheal intubation or laryngeal mask), lidocaine concentration, presence of URTI, and children’s age. In the sub-group analyses, there was no difference in outcomes identified. The sub-groups may have been underpowered to identify a difference.

When conducting leave one out sensitivity analyses for the laryngospasm outcome, leaving either of three studies resulted in no significant outcome difference. For the desaturation outcome, leaving out either of three studies resulted in no significant outcome difference.

Limitations

• Heterogeneity in the lignocaine protocols.
• Lack of standardisation of definitions of desaturation and laryngospasm.
• This meta-analysis could not identify patients with high-risk factors for PRAE.

The findings suggest that topical lidocaine may reduce the risk of laryngospasm, desaturation and sore throat. The heterogeneity in interventions and control groups make it difficult to determine which intervention/s may be associated with these outcomes.

Commentary

The pooled analyses do suggest an outcome benefit of topical lidocaine for laryngospasm, desaturation and sore throat. Should I spray it, nebulise it, smear it, put in in the cuff? Should I use it for just endotracheal intubation or for LMA’s too? Should I just save it for those at higher risk of PRAEs? I’m not sure. Generalising this to our patient populations is difficult because it is not clear which lidocaine intervention would be beneficial for which airway intervention.

Tags: #airway· #local-anaesthetics

Journal of Clinical Anesthesia

Submitted February 2026 by Dr Megan Wellbeloved

Summary

Following the premise that intraoperative burst suppression has been associated with postoperative delirium in adults these authors aimed to investigate whether intraoperative burst (IBS) suppression may show an association with emergence delirium (ED) in children.

Other secondary aims of the study included comparison of ED in propofol based and sevoflurane based anaesthetics and comparison of ED in two age groups (less than 2 years old and 2-5 years old).

A single centre prospective cohort study design was followed with appropriate ethics committee approval.

The study population included ASA 1 and 2 children from the age of 6 months to 9 years. The sample size calculated was 246 children. 246 children were recruited but after exclusion the sample group comprised 207 children.

The choice of a propofol or sevoflurane based technique was decided by the attending anaesthetist, and standard ASA monitoring was used. Patients in both propofol and sevoflurane groups received atropine fentanyl and rocuronium at induction and remifentanil was used during maintenance.

Sedline processed EEG monitoring was used from the start of induction to emergence and removal of the airway device. Attending anaesthetists were blinded to the EEG monitoring and alarms and anaesthetic doses were changed according to vital signs and experience.

Postoperatively ED was assessed using the PAED scale and pain assessed using the FLACC score.

Findings

Overall BS: 47.8% and overall ED: 24.6%

The BS group demonstrated patients with a lower age (27.68 +/-20.41 months) compared to the non BS group (41.85 +/-27.87 months). While a higher average BMI was noted in the BS group compared to the non BS group, no other demographic differences were shown between the two groups.

The authors also demonstrated a lower likelihood of BS in the propofol based anaesthetic patients. They also reported that a propofol technique reduced the risk of ED compared to sevoflurane by 57 %.

IBS increased the risk of ED with an OR of 8.262 (95% CI 3.478-19.626)

Limitations

The authors acknowledged limitations in using a wide range of age groups with a small sample size. They also discussed limitations when using a 4 lead EEG in assessing BS. The subjective nature of the PAED score when assessing ED was acknowledged.

Commentary

Emergence delirium (ED) does provide a challenge for anaesthesia and can have implications for patients and their carers. Techniques that help to reduce the risk of ED can be beneficial in the postoperative period.

Adult data does suggest an association between BS and postoperative delirium in adults although the evidence quality is low (Anesthesiology 2025; 142:107–20) and so it seems fair to establish whether there may be an association within the paediatric population.

This study did highlight a high number of BS in the sample group and an increased risk of ED in patients who had BS during the anaesthetic.

Limitations should be noted however. This was a single centre study with a small sample group resulting in poor quality data (with wide CI). The sample group included a wide range in age. It may be more appropriate to use a narrower age group and more specifically age 3-5 years where we would expect higher incidence of ED.

Assessment of ED using the PAED score can be subjective and may not be accurate.

The authors did not present other possible confounders such as the use of other agents ( α 2 agonists for example), alternative analgesic techniques (caudal or regional blocks). That said, findings from this study support the use of a TIVA based technique to reduce the incidence of ED.

It was also interesting in that anaesthetists were blinded to the EEG. Maintenance doses of anaesthesia may have been different with different incidences of BS if practitioners were not blinded to the EEG.

Future trials with larger groups may provide more clarification.

Tags: #general-anaesthesia· #delirium-emergence· #eeg-neuromonitoring· #monitoring· #postoperative-complications· #volatile-anaesthetics

Journal of Clinical Anesthesia

Submitted February 2026 by Dr Erik Anderson

Background:

Maintenance of oxygenation during micro-laryngoscopy and bronchoscopy is an anaesthetic challenge for paediatric anaesthetists. Anaesthesia goals are for a spontaneously breathing patient without an airway in situ. Ideally, patients should not move, cough, breath-hold or desaturate whilst still remaining adequately anaesthetised with minimal disruptions to surgical access.

Tubeless upper airway surgery in children is challenging and may be performed on complex paediatric patients with concurrent upper airway, cardiac or respiratory pathology. These procedures are often interrupted for rescue oxygenation.

Overview/ Summary:

Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a safe method to deliver oxygen to paediatric patients but its role in preventing desaturation in paediatric patients undergoing tubeless airway surgery is still being investigated.

This study compared THRIVE versus standard care during airway procedures.

**The primary aim ** was to assess the incidence of “relative desaturation events” i.e. patients who had at least one desaturation episode defined as a 4% drop from the patients’ baseline

Secondary aims were to assess: - overall frequency (total number) of “relative desaturation events (above)” - frequency of desaturations below 90%- “absolute desaturations” - surgical interruptions due to airway conditions

Methods and interventions

This is a prospective, randomised control trial conducted across three paediatric centres in the USA on patients aged 2 months to 18 years for elective surgery cases over a 40-month period (2020 to 2024).

Exclusion criteria: emergency surgeries, cyanotic heart conditions, Jet ventilated, COVID 19 positive, already- intubated patients, tracheostomy or contraindication to THRIVE (papillomatosis or facial fractures), neonates

Baseline sats were measured on each patient using a Massimo Pulse Co-oximeter.

All patients were placed in surgical suspension for the airway surgery.

**The THRIVE group ** received 2l/kg/min oxygen flows (max 70L/min) via the Optiflow system

The standard care group received oxygen via side-port of suspension laryngoscope or via ETT placed in oropharynx; i.e not actually standardised

Desaturations and airway interventions e.g. jaw thrust, Bag mask ventilation and intubations were captured by a research assistant in the OT.

Context of this study:

In July 2024, the High-flow nasal oxygen for children’s airway surgery to reduce hypoxemic events (HAMSTER) trial was published in the Lancet respiratory medicine journal. This was a multi-centre randomised trial in 5 tertiary centres in Australia which evaluated children 0-16 years randomised to undergo THRIVE oxygen therapy versus standard oxygen therapy for tubeless upper airway surgery. The results failed to show any benefit of THRIVE over standard therapy. There were no differences in adverse events and no difference in reducing desaturation-related surgical interruptions.

A limitation of the HAMSTER study was that it did not assess relative desaturation compared to the patient’s own baseline sats. This study evaluates relative desaturation as a secondary outcome.

Results:

Despite aiming for a sample size of 600 participants, only 144 participants were included.

• There were 73 patients in the THRIVE group and 71 patients in the standard care group
• Ages ranged from 2-18 years (mean age 5.1 years)
• Average procedure time 541 seconds

**Primary outcome: **

No difference 2 groups and incidence of relative desaturations < 4% of baseline

Secondary outcomes: ** - There was a difference in overall number of relative desaturations, with double the incidence in the standard care group compared to the THRIVE group - There was also difference in the total number** of desaturation events in the 2 groups - also double in the standard care group - There was no difference in the number of absolute desaturations below 90% in the 2 groups - There was no difference in number of surgical disruptions in the 2 groups

Limitations:

• Disproportionately low number of African-heritage patients
• Elective cases; complex patients, those with severe illness and emergencies were excluded
• Anaesthetists were not blinded to technique
• Titration of Fi02 and anaesthesia maintenance technique not standardised in standard care
• Exclusion criteria as above - certain patient groups were not evaluated
• Smaller sample size than initially planned

Take home message:

This study results agree with the results of the HAMSTER trial in Australia; they demonstrate and reinforce the non-superiority of THRIVE over standard care in tubeless airway procedures

Furthermore, there was: - No difference in the frequency of patients that desaturated 4% from baseline or below 90% - No difference in interruptions of surgical procedure

There was a difference in the overall number of desaturations events - THRIVE may benefit certain patients with cardiac/ respiratory risk factors. This warrants further investigation.

This study does not cover several important populations including emergency cases, complex disease, cyanotic heart conditions and neonates; further study would be required to evaluate THRIVE in these groups.

Tags: #general-anaesthesia· #airway· #monitoring· #respiratory

British Journal of Anaesthesia

Submitted February 2026 by Dr Timothy Marmion

Overview

This prospective cohort study examined whether the severity of obstructive sleep-disordered breathing (oSDB) influences postoperative pain following adenotonsillectomy in children aged 2–12 years. Given the pro-inflammatory state associated with oSDB and its potential interaction with nociception and opioid sensitivity, the authors hypothesised that children with more severe symptoms would experience greater postoperative pain and analgesic requirements.

Methods

Children undergoing adenotonsillectomy had preoperative assessment of oSDB severity using the modified STBUR (mSTBUR) questionnaire. Postoperative pain was measured using the Parents’ Postoperative Pain Measure (PPPM), recorded in a diary, twice daily for up to 14 days, with analysis focused on the first 10 postoperative days.

Pain trajectories were identified using group-based trajectory modelling, incorporating both complete and imputed datasets due to a substantial proportion of missing pain scores. Analgesic use and unscheduled hospital revisits were also recorded.

Results

Three distinct pain trajectories were identified: - Mild/brief pain (Trajectory 1) (44%)
- Moderate pain (Trajectory 2) (37%)
- Severe/prolonged pain (Trajectory 3) (19%)

Pain scores diverged early, with trajectory largely apparent from postoperative day 1. Children in the severe trajectory continued to experience clinically significant pain (PPPM >6) into the second postoperative week.

Higher preoperative mSTBUR scores were associated with increased likelihood of belonging to Trajectory 3 versus Trajectory 1 (OR, 0.52; 95% CI, 0.27—0.97; P=0.0395). This association was stronger in younger children.

Children in the moderate and severe trajectories required more analgesia and had significantly higher rates of unscheduled revisits, approximately 4-fold and 10-fold increases respectively compared with the mild group.

Discussion

This study demonstrates that post-adenotonsillectomy pain is not a uniform experience, but can be modelled to follow distinct and predictable trajectories. The association between oSDB severity and worse pain outcomes is clinically plausible, given the inflammatory and hypoxaemia-related mechanisms described in sleep-disordered breathing.

One of the most useful findings is the early separation of pain trajectories, suggesting that postoperative day 1 pain scores may help identify children at risk of prolonged recovery. This creates an opportunity for early escalation of analgesic strategies and closer follow-up.

There are several important limitations. Analgesic regimens were not standardised, introducing variability that may confound interpretation of pain scores and the rate of unscheduled revisits. Completed diaries were returned from 124 participants, leaving 121 (49%) of diaries requiring imputation for missing data. Pain assessment relied on parent-reported measures, which may be subjective and influenced by expectations or education.

Despite these limitations, the findings are relevant to everyday practice, particularly in highlighting a subgroup of younger children with severe oSDB who may be at increased risk of poor postoperative outcomes.

Strengths

• Prospective design with longitudinal pain assessment
• Use of trajectory modelling to capture clinically meaningful patterns
• Inclusion of patient-centred outcomes such as home pain and hospital revisits

Shortcomings

• High proportion of missing data requiring imputation
• Non-standardised analgesic regimens
• Single-centre design limits generalisability
• Reliance on caregiver-reported pain scores

Take Home Messages

• Post-adenotonsillectomy pain in children follows three distinct trajectories, with nearly 20% experiencing severe and prolonged pain.
• Greater oSDB severity (higher mSTBUR scores) is associated with worse pain outcomes and increased healthcare utilisation.
• Early postoperative pain (day 1) may help identify children at risk and guide more proactive, individualised analgesic strategies.

Tags: #day-surgery· #pain· #perioperative· #postoperative-complications