Daily, children undergo countless investigations and interventions, which require sedation and immobilization to ensure safety and accuracy. This remains associated with a persistent risk of sedation-induced life-threatening events as children are particularly vulnerable to adverse medical events and complications. Consequently, there is an urgent need to increase the safety of pediatric sedation and anesthesia. An ideal approach involves the use of drugs with fewer intrinsic side effects. In this context, on the basis of their pharmacokinetic properties, remimazolam (RMZ) and dexmedetomidine (DEX) were evaluated for their suitability as ideal sedatives. RMZ and DEX, both of which are currently available in pediatric medicine, have shown great promise in initial publications. To date, only very limited data concerning RMZ in small children are available. RMZ is a novel, ultrashort-acting benzodiazepine that is metabolized by tissue esterase, largely independent of organ function. It has a context-sensitive half-life of approximately 10 min, with minimal accumulation even with prolonged use. Its effects can be completely reversed with flumazenil. DEX, an isomer of medetomidine, is a potent α2-receptor-agonist with multiple indications in anesthesia and intensive care medicine. It has coanalgesic potential, allows for ‘arousal sedations’ and has a low profile for cardiorespiratory side effects. DEX is metabolized in the liver and is predominantly excreted renally. Both drugs show potential in the prevention and treatment of delirium, with DEX having additional neuroprotective effects. DEX and RMZ possess several properties of an optimal sedative, including clinically insignificant main metabolites and a broad dosage range, indicating their potential to reduce the incidence of sedation-related life-threatening events in children. However, further clinical research is necessary to better evaluate their potential risks.

Introduction: Inducing general anesthesia (GA) in children can considerably affect blood pressure, and the rate of severe critical events owing to this remains high. Cerebrovascular autoregulation (CAR) protects the brain against blood-flow-related injury. Impaired CAR may contribute to the risk of cerebral hypoxic–ischemic or hyperemic injury. However, blood pressure limits of autoregulation (LAR) in infants and children are unclear.Materials and methods: In this pilot study CAR was monitored prospectively in 20 patients aged <4 years receiving elective surgery under GA. Cardiac- or neurosurgical procedures were excluded. The possibility of calculating the CAR index hemoglobin volume index (HVx), by correlating near-infrared-spectroscopy (NIRS)-derived relative cerebral tissue hemoglobin and invasive mean arterial blood pressure (MAP) was determined. Optimal MAP (MAPopt), LAR, and the proportion of time with a MAP outside LAR were determined.Results: The mean patient age was 14 ± 10 months. MAPopt could be determined in 19 of 20 patients, with an average of 62 ± 12 mmHg. The required time for a first MAPopt depended on the extent of spontaneous MAP fluctuations. The actual MAP was outside the LAR in 30% ± 24% of the measuring time. MAPopt significantly differed among patients with similar demographics. The CAR range averaged 19 ± 6 mmHg. Using weight-adjusted blood pressure recommendations or regional cerebral tissue saturation, only a fraction of the phases with inadequate MAP could be identified.Conclusion: Non-invasive CAR monitoring using NIRS-derived HVx in infants, toddlers, and children receiving elective surgery under GA was reliable and provided robust data in this pilot study. Using a CAR-driven approach, individual MAPopt could be determined intraoperatively. The intensity of blood pressure fluctuations influences the initial measuring time. MAPopt may differ considerably from recommendations in the literature, and the MAP range within LAR in children may be smaller than that in adults. The necessity of manual artifact elimination represents a limitation. Larger prospective and multicenter cohort studies are necessary to confirm the feasibility of CAR-driven MAP management in children receiving major surgery under GA and to enable an interventional trial design using MAPopt as a target.

Objective Recommendations on nasal intubation depths in term or preterm newborns are scarce, although this is the preferred route in some countries. Postmenstrual age (PMA) and weight-based recommendations were recently published by our group. Design A prospective quality assurance study Setting Single-centre study (University Children’s Hospital Tübingen) Patients All nasally intubated term and preterm infants between August 2021 and August 2023 Interventions Physicians were free to choose the method of orientation for the insertion depth (our recommendations vs other’s (eg, endotracheal tube (ETT) tip markers)). Subsequently, chest X-rays were performed. Correct ETT placement was defined as the tip visible between thoracic vertebrae 1–3. X-ray investigators were blinded to the method of orientation. Main outcome measures Main outcome was the rate of correct ETT placements using our previous recommendation compared with other orientations. Secondary, a subgroup analysis for infants <1000 g and a comparison of PMA-based orientations by European Resuscitation Council (ERC) guidelines were performed. Results 114 intubations/infants were analysed (39 weight-based; 26 PMA-based; 49 others). Median PMA (IQR) was 30 0/7 weeks (26 6/7–35 0/7), weight 1310 g (793–2300). Correct ETT placement was in 74% following our recommendations versus 55% in others (p=0.046). No difference was seen between PMA-based and weight-based recommendations (77 vs 69%; p=0.57). 48 infants <1000 g showed even clearer results; based on ERC guideline, correct placement would have been 27%. Conclusions Our previously published recommendations for nasal intubation depths are applicable in routine care leading to a more accurate ETT placement than with other orientations.

Solid tumors of the cervicothoracic junction, the posterior mediastinum, or bilateral dorsal thoracic tumors represent a challenge in pediatric surgical oncology. The aim of this study was to evaluate trap-door thoracotomy and clamshell thoracotomy as surgical approaches. A single-center retrospective study of children with solid tumors in these specific localizations was performed. From 2015 to 2023, 26 children (17 girls; 9 boys) were treated at a median age of 54 months (range 8–229). Tumor resection was performed for neuroblastoma (n = 11); metastatic disease (n = 7); malignant rhabdoid tumor (n = 4); Ewing sarcoma (n = 1); inflammatory myofibroblastic tumor (n = 1); rhabdomyosarcoma (n = 1); and neurofibroma (n = 1). The surgical goal of macroscopic complete excision was achieved in all of the 14 children who underwent trap-door thoracotomy and in 11 of the 12 children who underwent clamshell thoracotomy. There were no major complications. At a median follow-up of 8 months (range 0–60), the disease was under local control or in complete remission in 66.7% of the children. In conclusion, surgical resection of solid tumors of the cervicothoracic junction in children can be performed safely and successfully with trap-door thoracotomy and with clamshell thoracotomy for posterior mediastinal or bilateral dorsal thoracic tumors.

Background/Objectives: Efficient postoperative recovery room care in pediatric patients is crucial for optimizing perioperative safety, patient outcome, and effective pain management. However, this area is frequently underemphasized, leading to higher complication rates compared to the operating room, which in turn increases healthcare costs. Improving pediatric recovery room care offers a significant opportunity to enhance the quality and safety of perioperative pediatric care. From an economic perspective, this is prudent; however, more importantly, every child has the right to the highest attainable standard of health, as outlined by the United Nations. Key aspects of recovery room care include ensuring adequate staffing and equipment, while also prioritizing the child’s privacy and parental presence, both of which are crucial for enhancing patient well-being. A +multimodal approach to postoperative pain management is essential for minimizing fear and stress, alongside strict adherence to established guidelines for the management of postoperative nausea, vomiting, and emergence delirium. Furthermore, addressing risk factors such as hypothermia and airway complications, as well as promoting early intake of clear fluids, plays a crucial role in optimizing pediatric recovery. Organizational strategies such as quality improvement initiatives, structured handovers, standardized care protocols with checklists, continuous staff training, and well-defined discharge criteria are further essential components to reduce translational gaps and to enhance postoperative pediatric safety. Conclusions: Improving pediatric postoperative anesthetic care is a multifaceted challenge for all healthcare providers that can significantly enhance care quality and safety while also reducing costs. Success in this area requires addressing both structural and medical factors.