July 2026

Anesthesia and analgesia

Submitted April 2026 by Dr Su May Koh

Review summary

This excellent editorial highlights the current evidence for videolaryngoscopy (VL) in improving first pass success rates for intubations in infants compared to direct laryngoscopy (DL). It also stresses the need for a culture change in the way we view VL and how we should teach our trainees.

Key findings

The authors highlight that numerous clinical trials over the last 5 years have repeatedly demonstrated a dramatic improvement in first pass success rates during infant intubations with VL compared to DL. However, there remain a somewhat slower rate of VL adoption from paediatric anaesthesiologists which is not due to a lack of access issue.

Interestingly in Bai et al's recent survey of paediatric anaesthesiologists only 40% would use VL as an initial airway technique in premature infants and neonates, despite 93% of respondents having access to VL in the OR. Uchimani et al recently also showed that the benefits of VL was pronounced in novice trainees with first pass success rates in infants for first year trainees with VL at 86.9% compared to DL at 74.6%.

The authors argue that it is time for all of us to embrace VL for infants and neonates and that whilst fundamental infant laryngoscopy skills are still important - babies do not need to pay the price for this. Also, that DL skills can still be effectively taught using a standard (non-hyperangulated) VL blade. The authors compared this to the use of ultrasound in neck internal jugular (IJV) line insertions as well, suggesting that surely we would NOT advocate abandoning ultrasound for IJV line insertions.

The authors also advocate that we as supervisors must be deliberate in our coaching and feedback during the procedure and suggests a standardized coaching language. VL with trainees also clearly allows a shared mental model, real-time feedback and improved visualisation for the trainee and supervisor. The authors argue that VL should be used a first line in infants and neonates and as skills improve a graduated transition can occur to allow DL skills to develop. Significant blood or vomitus in the airway or failure of the VL equipment, may limit the VL views so DL skills are still important.

Strengths and Limitations

This is an excellent review of the recent literature with key points highlighted well. It is well structured and well argued. Although the authors don't specifically mention this - one also wonders if operator ego is another factor leading to a slowed uptake of VL in the neonatal and infant group.

Bottom line

The evidence for VL as first line in neonates and infants is clear - we should all be using VL as first line as it improves our first pass success rates. This has been a definite change in my practice over the last 5 years and I also insist that my trainees should use standard VL as first line in this population as it improves real-time coaching and teaching. As the authors so rightly point out - why should babies have to pay the price!

Anesthesiology

Submitted April 2026 by Dr Erika Strazdins

Review summary

What defines a ‘good’ anaesthetic for a child? Is it uneventful airway management, a cannula that goes in the first time, and physiologic stability? Or a positive and pain free experience that they are not afraid to face again?

This original research explores how children, parents, and healthcare professionals prioritise outcomes in paediatric anaesthesia, and the barriers to and facilitators of positive and negative experiences. While some outcomes such as pain management, emotional wellbeing, and relationships are shared, their meaning and importance diverge across groups in ways that shape the overall experience. These findings, as well as an imbalance between the groups in areas such as education and safety provide insight into why a technically perfect anaesthetic as viewed by a clinician may still feel like a difficult experience for a child and their family. This research challenges traditional perioperative outcome measures, and supports the development of a more patient and family centered paradigm.

Key findings

Patients and parents experienced anaesthesia as a longitudinal journey beginning at admission and ending back at home, whereas clinicians conceptualised it as a discrete episode of care.

Safety was prioritised by clinicians (102/136 responses), yet was overwhelmingly underrepresented in parent and patient narratives (29/172 and 12/51). This paradox may reflect a differing awareness of risk or the implicit trust that safety is assured.

Parents strongly emphasised education as a key facilitator of a positive anaesthetic experience (161/172), contrasting with only slightly more than half of providers (77/136). This suggests that parents desire more information than healthcare providers anticipate or routinely provide.

Perhaps unsurprisingly, parents experienced routine aspects of perioperative care, such as prolonged fasting, as significant contributors to distress and behavioural dysregulation.

Often differences between the groups were not absolute but reflected variation in emphasis, expectations, and lived experience in these domains. For instance, while pain emerged as a shared priority in patients, parents, and providers, the emotional meaning differed. Providers often framed pain as an inevitable consequence of surgery, whereas patients and parents experienced it as a potentially modifiable determinant of recovery quality, impacting mobility, sleep, and overall wellbeing. Patients and parents discussed the social and emotional support they received and the comfort of their environment as facilitators of recovery. These factors were strongly echoed by health care providers.

Finally, there was agreement across groups on what constitutes an ideal outcome: minimal pain, absence of complications, and no lasting negative emotional impact or fear of future procedures.

Strengths

This is original research specifically seeking patient relevant clinical outcomes in paediatric anaesthesia. Semistructured interviews facilitated an exploration of experiences, values and priorities beyond what quantitative methods can capture.

This qualitative research had sound methodology, with clear application of Modified Grounded Theory, transparent coding processes, and attention to researcher background.

359 interviews, across 8 countries, and multiple stakeholder groups improves ecological validity. In addition, our Oceania region was well represented in the sample group, increasing local relevance. The inclusion of multi disciplinary health care providers including anaesthetists, surgeons, and nurses, strengthens the relevance across the perioperative pathway.

Limitations

Patient perspectives (51) were comparatively underrepresented, with interviews weighted toward parents (172) and healthcare providers (136). The exclusion of children less than 8 as interviewees means that the younger children’s experiences were captured indirectly through parent perspectives, which may not fully reflect the child’s lived experience.

Notably, patient interviews were only conducted in North America and Oceania, limiting the cultural generalisability of children’s perspectives.

The parent cohort was highly educated (60% university or higher), potentially limiting generalisability across diverse cultural and health literacy contexts.

Although internationally diverse, the sample was predominantly from Western countries, and Caucasian (64% of patients, 51% of parents, and 61% of providers), which may limit the cultural generalisability of findings. There were limited First Nations peoples.

The study focused on lower-risk (ASA ≦3) elective surgical populations, limiting applicability to more complex or high-risk cohorts and to non-surgical procedures (such as endoscopy, interventional radiology, imaging).

Bottom line

For children and their families, the success of anaesthesia is not measured in physiological stability, but in how the experience feels for the entire health care episode well before, during, and long after their surgery.

This study reveals shared foundations, but significant divergence between health care provider defined outcomes and the lived experience of paediatric anaesthesia. While safety and minimising complications remains essential to our practice, pain, education, emotional wellbeing, and the hospital environment shape how anaesthesia is remembered by children and their parents. These differences suggest that improving paediatric anaesthesia is not just a technical challenge, but a relational and communicative one.

It provides a compelling foundation for developing child and family centred outcome measures, and challenges us to rethink what success in paediatric anaesthesia means.

Tags: #perioperative

Paediatric anaesthesia

Submitted April 2026 by Dr Nicole Wong

Review summary

This retrospective cohort study evaluated the association of multispecialty surgical care and perioperative risk in paediatric patients with Trisomy 21.

The multisystem comorbidities of Trisomy 21 patients commonly necessitate frequent surgical, interventional and imaging procedures requiring general anaesthesia. As a result, there is potential for a higher frequency of perioperative safety events in children with Trisomy 21 compared to their age-matched peers.

In this study, multispecialty surgical care refers to performing two or more procedures from different subspecialties under the same anaesthetic. This is a proposed method to minimise perioperative risk by avoiding repeated inductions, airway manipulations and recovery from anaesthesia, as well as reducing the frequency of healthcare visits and the emotional burden on children and their families.

Patient demographic information, procedural data and perioperative safety events were retrospectively extracted from all anaesthesia cases performed at Children’s Wisconsin over 9.6 years. Perioperative safety events were defined as either an intraoperative event (from anaesthesia start to PACU discharge) or a postoperative event (within 48 hours from PACU discharge) occurring within a single case. Severity of these safety events were classified based on the extent of care escalation required.

Key findings

This cohort included 219,626 anaesthesia cases performed in 120,299 patients. Of this, 3,873 anaesthesia cases were performed in 995 patients with Trisomy 21.

The Trisomy 21 cohort were of lower age and weight, higher ASA, and had longer anaesthesia duration compared to the rest of the anaesthesia population.

Compared to the total study population, the Trisomy 21 cohort and had a higher likelihood of:

• multiple anaesthetics per patient (OR = 8.02 [95% CI 7.11-9.04])
• multispecialty care (OR = 3.95 [95% CI 3.6-4.3])
• perioperative safety events (OR = 5.65 [95% CI 4.51-7.08])

Independent risk factors associated with perioperative safety events within the Trisomy 21 population included:

• ASA > 3
• African American ethnicity
• anaesthesia duration (> 240 mins)
• multispecialty case

The number of anaesthetics per patient was not associated with an increased risk of safety events – it was identified as a protective factor instead.

Commentary

This study provides an insight into some of the risk factors affecting perioperative safety events and evaluates the risks of multispecialty surgical care for children with Trisomy 21. Its strengths include the large study population and the use of validated scoring tools to classify and quantify the severity of perioperative safety events.

This study has some limitations that can affect the generalisability and applicability of key findings reported.

The single-centre, retrospective design, and the exclusion of trauma surgeries from multispecialty case analysis may introduce selection bias. Additionally, the lack of categorisation of the reported perioperative safety events and the limited description of the surgical subspecialties involved in multispecialty cases may restrict the study’s insights. Although this study analysed a large sample size, the data was collected over a prolonged period (9.6 years), during which perioperative safety practices and guidelines may have evolved, potentially acting as a confounding factor. Furthermore, a large proportion of safety events were retrospectively self-reported by clinicians, which may have led to recall bias.

Given the retrospective design of this study, a definitive causal relationship between the identified risk factors and safety events cannot be established. Anaesthetic duration and multispecialty cases were identified as significant risk factors; however, the underlying reasons influencing anaesthetic duration and the factors associated with multispecialty surgical care were not conducted. Consequently, additional risk factors, such as clinician seniority or time of day surgery occurred, may not have been captured in this analysis.

Although the authors alluded to the potential benefits of multispecialty surgical practice – such as decreasing healthcare costs, improved time efficiency, and decreased emotional burden on families – the economic impact or perceived benefits by families were not evaluated.

Take home messages

Multispecialty surgical care is often opportunistically utilised within institutions to reduce anaesthetic exposure, ease scheduling pressures, and lessen the emotional burden on children and their families. However, this study demonstrated that multispecialty surgical care may increase the risk of perioperative safety events, whilst a greater number of anasesthetic exposures per patient was identified as a protective factor instead. Consequently, careful scheduling practices are warranted, such as considering separate single specialty cases or limiting the duration of multispecialty scheduling to less than four hours.

In our institution planned combined procedures are typically limited to diagnostic pairings (e.g. MRI and lumbar puncture), procedures with linked or associated pathologies (e.g. cleft palate repair and myringotomy tube insertion), or trauma-related cases. In our setting, multispecialty surgical procedures are not limited to children with Trisomy 21, but are also utilised for children with other chronic, multisystem conditions (e.g. cerebral palsy), or those with significant behavioural concerns where repeated perioperative management may be challenging.

Whilst multispecialty care may offer perceived benefits, it is important to consider institutional factors, including proceduralist availability, access to appropriate theatre environments, and equipment constraints (e.g. MRI availability). Overall, this paper provides a valuable foundation for future research to further evaluate the risk-benefit balance of multispecialty surgical care in the peadiatric population to help inform clinicians and families about competing interests and how best to deliver such care safely if necessary or preferred.

Tags: #general-anaesthesia· #postoperative-complications

Paediatric anaesthesia

Submitted April 2026 by Dr Erika Strazdins

Review summary

Paediatric anaesthestists may overestimate aspiration risk while underestimating the physiological and behavioural consequences of prolonged fasting. Fasting time is a key factor of operating theatre scheduling, driven by concern for the morbidity and potential mortality associated with rare event of pulmonary aspiration. These fasting times are shaped by professional guidelines, and many clinicians feel medicolegally vulnerable when deviating from them, even where guidelines allow clinical discretion. This editorial challenges the arguably disproportionate anxiety surrounding aspiration risk in infants and neonates, arguing that excessive adherence to restrictive milk fasting guidelines may create more common and immediate harms such as hypovolemia, hypoglycaemia, and distress at induction, than the aspiration events they seek to prevent.

Key findings

Pulmonary damage depends on the volume, acidity, and particulate content of aspirated gastric contents.

The authors highlight that the commonly cited critical volume for pulmonary injury derive from animal and primate studies, making it an imperfect measurement. In humans, although gastric emptying varies with age, feed volume, and route of feeding, normal liquid gastric emptying in infants and children younger than five exceeds 80% by three hours. Milk (both breast and formula) demonstrates a slower decline than clear fluids, but importantly, the variability of gastric emptying is similar between milk and clear fluids. Thus, the traditional assumption that milk behaves like a solid in the stomach and therefore require prolonged fasting is poorly supported.

As anaesthetists, we know that there are other factors aside from gastric volume and contents that contribute to the volume aspirated into the lungs. The authors highlight the findings from a prospective one-year survey of nearly 120, 000 children at eleven specialist pediatric hospitals in the UK. Firstly, inadequate anesthesia or poor control of the airway during induction, maintenance, and emergence all contribute to aspiration risk. Moreover, patient factors such as raised intra-abdominal pressure and comorbidities impact on aspiration incidence. This shifts focus from rigid fasting times toward high quality airway management and thoughtful preoperative assessment.

Strengths

A key strength of the editorial format is its ability to provide expert interpretation and clinical context around a topic where evidence is limited and practice is often guided by tradition rather than strong science. The authors challenge entrenched assumptions and translate the literature into practical recommendations for paediatric anaesthesia.

The short, narrative style makes the article accessible and engaging. It invites reflection on routine fasting practices and encourages readers to question whether current habits are evidence based or driven by dogma and defensive medicine. The authors add considerable authority. The primary author is a leader in original research around paediatric fasting, and other two authors are well established figures in paediatric anaesthesia research. These authors’ backgrounds span America, England, and Oceania. Their combined expertise makes this editorial a persuasive and credible call for reassessment of milk fasting guidelines in infants.

Limitations

The editorial format has intrinsic limitations. As an expert opinion piece, it reflects the authors’ interpretation of the literature and their clinical experience, rather than presenting new primary data. Their argument is persuasive, but it relies heavily on synthesis and extrapolation from older animal studies, observational studies, and physiologic reasoning.

The limited word count of an editorial restricts exploration of how more liberal fasting strategies could be balanced against patient comorbidities, emergency surgery, or babies and infants with delayed gastric emptying. While the editorial advocates flexibility, translating this safely into routine practice still requires clinician judgment and organisational support.

Bottom line

Strict adherence to fasting guidelines may not always serve the best interests of infants and neonates. Excessive fasting has known and common risks including operating theatre delays, hunger, dehydration, hypoglycaemia, and greater behaviorual distress at induction.

One practical strategy proposed is offering clear fluids after the final milk feed in babies and infants on milk-based diets, such as warmed 5% or 10% glucose solutions. This may improve hydration, calorie intake, and reduce preoperative distress.

In this vulnerable population, a more liberal provision of fluids is not simply about comfort, it may also mitigate common risks in anaesthesia. The authors argue that the greater danger may lie not in pulmonary aspiration itself, but the sequelae from the culture of fear surrounding it.

Paediatric anaesthesia

Submitted April 2026 by Dr Barney Rathnayaka Mudiyanselage

Review summary

This is a single-centre study from Berlin with the goal of further understanding the perioperative EEG of the paediatric population throughout key phases of anaesthesia and how it may vary with age.

A total of 147 frontal EEGs from children ranging from 1 month to 8 years of age presenting for elective surgery were recorded prospectively during the awake state, induction, maintenance, and return of consciousness phases of anaesthesia.

The patients were divided into four groups by age: - 0–5 months - 6–11 months - 12–23 months - Over 24 months.

EEG data were acquired using the Narcotrend monitor. The raw EEG and frequency bands were subsequently compared between the groups.

Key findings

There was signification variation in EEG activity across all four measured phases of anaesthesia with increasing age. In particular, there was a clear difference in EEG frequency bands and their changes when comparing the 0–6 month group with the three older age groups.

The findings are visually displayed in the article using four box-and-whisker graphs which summarise the following findings:

When comparing the raw EEG response between age groups:

• All age groups had predominantly delta activity.
• Overall EEG power increased with age.
• Total EEG activity for all groups followed the same pattern: an increase from baseline at induction, a decline during maintenance, followed by a return to baseline or slightly below during the return to consciousness.

When comparing frequency bands between age groups:

Delta activity: Showed a consistent trend during each phase of anaesthesia across all groups. The signal in variation between phases was more pronounced in older children and reached statistical significance, it failed to do so in the youngest age bracket

• Induction: All age groups showed a step increase in delta activity

• Maintenance: All age groups had a reduction in delta activity from their baseline measure

• Emergence: Delta activity returned to baseline or slightly lower, with increasing age at return of consciousness.

Alpha activity: Was discernibly different in the 0–6 month age group compared with the three older groups. Children under 6 months had no significant variation in alpha frequency over the four measured phases.

In contrast, children over 6 months showed an increase in alpha activity during induction and maintenance, with older groups demonstrating a progressively greater and statistically significant increase in alpha frequency from induction to maintenance with age.

At return of consciousness both alpha beta activity returns to baseline.

Beta activity : Remained similar across groups but when displayed graphically the pattern appeared to be follow that of alpha activity as age increased.

Strengths

Like most research in paediatric anaesthesia, the study was pragmatic in its approach at all steps of the study to accomodate real life limitations.

This is one of the few studies at present which follows the paediatric EEG through four key phases of anaesthesia with a large enough cohort to produce a statistical difference between age groups.

The selection criteria was appropriate and clear to achieve its specific goal: to provide further information for the construction of the foundation of basic paediatric EEG use in anaesthesia. Exclusion criteria included patients with neurological and psychiatric pathology excluding procedures shorter than 15 minutes.

The mode of measurement is generalisable as frontal EEG monitoring is currently the most commonplace approach to depth of anaesthesia EEG monitoring in Australasia . Attempts were made to record periods of the procedure with minimal interference; incomplete data sets were excluded.

All groups had enough patients and points of data to provide statistically significant results for the primary outcome with statistical analysis taking into consideration many confounding factors for example duration of surgery and end tidal volatile concentration. This was also supplemented with the older age groups being powered well enough to provide significant findings in the study’s secondary outcomes ( the change in alpha power through each phase).

Limitations

An interesting point of difference between groups was the practice of premedication prior to baseline measurement. Children under 6 months were not pre-medicated whilst 94% of the other participant groups received a dose of midazolam prior to baseline measurement. These results may therefore be more generalisable to a paediatric anaesthesia practice with a high rate of midazolam premedication.

The anaesthesia regimen for induction and maintenance was also not controlled for the study; intravenous anaesthesia techniques were used more frequently in older children.

Return of consciousness was also challenging to measure - clinical endpoints are subjective and variable, they also change with age, which may impact on the precision of reporting.

Finally, a potentially useful signal within the youngest age bracket was the variation in delta activity with each phase of anaesthesia. The group was not powered to show statistical significance for this variation; a subsequent, better-powered study might provide a useful reference for assessing depth in this vulnerable demographic.

Bottom line

The findings of this study indicate that the EEG varies with a child’s age, with alpha activity beginning to appear under general anaesthesia at over six months of age during induction and maintenance with alpha activity being a useful measure to assess depth in children over six months of age.

Children under six months of age pose greater difficulty due to their lack of the typical frequency bands described above. Instead, this paper suggests that the clinician might to depend on the patients baseline delta activity and its stepwise change throughout anaesthesia to assess adequacy. This trend itself was a secondary outcome and did not reach statistical significance within this study.

The difference in EEG activity at baseline between adults and children indicate that the interpretation of a raw EEG differs sufficiently from adult practice to require an alternative approach.

Further reading and clinical context

As a clinician who uses processed EEG monitoring in my work as an anaesthetist, I spoke with a colleague who is highly published in the field of paediatric EEG in anaesthesia for further context.

The current state of knowledge in this area includes the following findings:

• That the EEG changes from birth to maturation, and that alpha activity develops from around 6 months of age

• That Density Spectral Array (DSA) is a helpful parameter for monitoring depth of anaesthesia in the paediatric population

• That the DSA is not helpful for lightening the plane of anaesthesia

• That alpha activity is a supplementary marker for depth of anaesthesia, and cannot replace vigilant assessment of clinical response and an understanding of the pharmacokinetics of the anaesthetic agent being used

My use of routine EEG monitoring is purely for total intravenous anaesthesia when using paralysis, or in the high risk patient to avoid burst suppression. My preference is for a monitor that can report a DSA.

The spectrogram provides an simple to interpret additional marker when assessing the depth of anaesthesia with propofol TIVA, with the presence of an alpha band marking adequacy of depth, and loss of this band as an excess in depth - a sign which is known precede burst suppression. Separation between the alpha and delta bands indicates lightening of anaesthesia with propofol.

The spectrogram shows a very different pattern with propofol and sevoflurane, with no separation of the alpha and delta bands on spectrogram under general anaesthesia.

Other monitors may only provide an EEG waveform, from which it is possible to detect slow-wave anaesthesia, burst suppression, or high frequency activity consistent with the awake state. Dimensionless indices such as the BIS value may be more limited by their lower granularity.

Despite its limitations, the study gives serves as a primer for the clinician looking to translate their knowledge of depth-of-anaesthesia monitoring to the paediatric population - in particular, the differences between < 6 month-olds and older children.

References

1. L. Cornelissen, S. E. Kim, P. L. Purdon, E. N. Brown, and C. B. Berde, “Age-Dependent Electroencephalogram (EEG) Patterns During Sevoflurane General Anesthesia in Infants,” eLife 4 (2015): e06513.

2. M. Markus, H. Nagelsmann, M. Schneider, L. Rupp, C. Spies, and S. Koch, “Peri- and Intraoperative EEG Signatures in Newborns and Infants,” Clinical Neurophysiology 132, no. 12 (2021): 2959–2964.

3. D. Beekoo, K. Yuan, S. Dai, et al., “Analyzing Electroencephalography (EEG) Waves Provides a Reliable Tool to Assess the Depth of Sevoflurane Anesthesia in Pediatric Patients,” Medical Science Monitor 25 (2019): 4035–4040.

4. M. H. Y. Long, E. H. L. Lim, G. A. Balanza, J. C. Allen, Jr., P. L. Purdon, and C. L. Bong, “Sevoflurane Requirements During Electroencephalogram (EEG)-Guided vs Standard Anesthesia Care in Children: A Randomized Controlled Trial,” Journal of Clinical Anesthesia 81 (2022): 110913.

5. C. A. Sullivan, C. Egbuta, R. S. Park, K. Lukovits, D. Cavanaugh, and K. P. Mason, “The Use of Bispectral Index Monitoring Does Not Change Intraoperative Exposure to Volatile Anesthetics in Children,” Journal of Clinical Medicine 9, no. 8 (2020): 2437.

6. J. Tokuwaka, T. Satsumae, T. Mizutani, K. Yamada, S. Inomata, and M. Tanaka, “The Relationship Between Age and Minimum Alveolar Concentration of Sevoflurane for Maintaining Bispectral Index Below 50 in Children,” Anaesthesia 70, no. 3 (2015): 318–322.

7. L. Cornelissen, S. E. Kim, J. M. Lee, E. N. Brown, P. L. Purdon, and C. B. Berde, “Electroencephalographic Markers of Brain Development During Sevoflurane Anaesthesia in Children up to 3 Years Old,” British Journal of Anaesthesia 120, no. 6 (2018): 1274–1286.

8. J. Y. Chao, R. Gutierrez, A. D. Legatt, et al., “Decreased Electroencephalographic Alpha Power During Anesthesia Induction Is Associated With EEG Discontinuity in Human 

9. L. Seltzer, M. F. Swartz, J. Kwon, et al., “Neurodevelopmental Outcomes After Neonatal Cardiac Surgery: Role of Cortical Isoelectric Activity,” Journal of Thoracic and Cardiovascular Surgery 151, no. 4 (2016): 1137–1142.Infants,” Anesthesia and Analgesia 135, no. 6 (2022): 1207–1216.

10. Power & Kam Chapter 11 - Consciousness, EEG, Sleep and Emotions

11. Miller’s Chapter 40 - Monitoring the State of the Brain

12. Rampil, I. A Primer for EEG Signal Processing in Anesthesia. Anesthesiology 1998; 89:980-1002

13. Viertio-Oja, H. Description of the Entropy algorithm as applied in the Datex-Ohmeda S/5 Entropy Module. Acta Anaesthesiol Scand 2004; 48: 154–161

14. Medtronic. Monitoring Consciousness. Using the Bispectral Index (BIS) brain monitoring system.

Tags: #general-anaesthesia· #eeg-neuromonitoring· #monitoring· #neonatal