The global COVID-19 pandemic highlighted significant existing supply–demand imbalances in anesthesia workforce, particularly impacting non-operating room anesthesia. Despite documented risks and mortality rates associated with pediatric procedural sedation and analgesia (PPSA) outside the operating room (OR), there is a pressing need for improvements in safety infrastructure. Comparative analysis with international practices reveals that anesthesiologists’ involvement is associated with fewer adverse events and improved outcomes. However, lower reimbursement rate for sedation and anesthesia workforce shortage, and decentralized health resources are contributing factors to limit their participation in PPSA outside the OR in Japan. Enhancing the involvement of anesthesiologists through the public health frameworks such as “high-risk approach” and “population approach” can contribute to improvement of the safety and quality of PPSA. By tackling these challenges and implementing effective solutions, anesthesiologists can play a key role in ensuring safer and more effective PPSA outside the OR. Future challenges include enhancing training, addressing reduced clinical exposure due to work style reform, and developing effective educational systems. Research on improved educational approaches and fundamental outcome indices is crucial for improving PPSA practices outside the OR.

Background: Despite significant advancements in pediatric anesthesia training and guidelines, the incidence of severe critical events in children undergoing anesthesia in Asia remains under-researched. This knowledge gap is particularly pressing given the rare but life-threatening nature of such complications. While studies from high-income countries report a decline in pediatric anesthesia-related mortality, similar data from developing regions, including Asia, are sparse and suggest higher risks. Objective: The Peri-anesthetic Morbidity in Children in Asia (PEACH in Asia) study aims to provide a comprehensive assessment of the incidence and risk factors associated with severe critical events in pediatric anesthesia across Asia. This multinational, multicenter, prospective observational study seeks to enhance understanding of pediatric anesthesia-related risks and variability in practices within the region. Methods: The study will enroll children aged birth to 15 years undergoing elective or urgent diagnostic or surgical procedures requiring sedation or general anesthesia, with or without regional analgesia. Data collection will focus on severe critical events occurring during and up to 60 minutes post-anesthesia, including laryngospasm, bronchospasm, pulmonary aspiration, drug errors, anaphylaxis, cardiovascular instability, neurological damage, cardiac arrest, and post-anesthetic stridor. The study will also capture patient demographics, medical history, and procedural details to identify potential risk factors. Results: The pilot phase of the PEACH in Asia study, conducted from May to June 2023, included 330 patients from ten institutions across nine countries. Preliminary findings revealed a severe critical event incidence rate of 12.4% [95% CI: 9.2-16.4]. Based on these results, the main study plans to recruit approximately 10,958 children across 15 to 30 Asian countries to achieve robust statistical power and refine risk factor identification. Conclusion: The PEACH in Asia study represents a critical step towards understanding and mitigating the risks associated with pediatric anesthesia in Asia. By providing data-driven insights into the incidence of severe critical events and regional variations in anesthesia practices, this study aims to inform and improve pediatric anesthesia protocols across the continent.

Postoperative vomiting (POV) after paediatric strabismus surgery poses both clinical and economic challenges. This study evaluates the cost-effectiveness of different anaesthesia regimens, focusing on the addition of ondansetron (OND), in preventing POV. A cost-effectiveness analysis was conducted from the perspective of a Japanese public healthcare payer using retrospective cohort data of children (aged 3–15 years) undergoing strabismus surgery at three institutions (February 2016–November 2023). The primary outcome measure was cost per averted POV (aPOV) within 24 hours post-surgery. Incremental cost-effectiveness ratios were calculated, and sensitivity analyses accounted for uncertainties. A total of 2772 patients were included. Total intravenous anaesthesia (TIVA) regimens were compared, as OND was used only in TIVA regimens. The aPOV rate for TIVA with sub-Tenon block and dexamethasone (DEX) was 91.0%, whereas TIVA with sub-Tenon block, DEX, and OND had an aPOV rate of 96.3%. The incremental cost of adding OND was €21.2, resulting in an incremental cost-effectiveness ratio of €400.6 per aPOV. A sensitivity analysis showed OND cost was the most influential factor. The cost-effectiveness acceptability frontier showed the probability of cost-effectiveness for TIVA+DEX ranged from 0% to 97.4% for thresholds of €0–€200 per aPOV, whereas TIVA+DEX+OND raged from 0% to 9.3%, and TIVA only ranged from 100% to 0%. TIVA with DEX alone is the most cost-effective regimen for preventing POV in paediatric strabismus surgery in the current Japanese public healthcare system. The addition of OND in TIVA regimens may not be justified from the viewpoint of cost-effectiveness.

Purpose: This simulation-based cost-effectiveness analysis evaluates various sedation regimens for pediatric magnetic resonance imaging (MRI) in Japan. Methods: A decision tree model was developed for children aged 3 years with ASA-PS class I/II to compare four sedation regimens: oral triclofos sodium, IV midazolam, IV dexmedetomidine, and IV propofol. The primary outcome was averted sedation failure (aSF). Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses, including Monte Carlo simulations and cost-effectiveness acceptability curves (CEACs), were performed. A 0% discount rate was applied. Our systematic literature search determined success rates for each sedation or general anesthesia regimen. Results: The cost-effectiveness plane demonstrated the efficiency frontier connecting triclofos sodium, propofol, and general anesthesia. Compared to oral triclofos sodium, propofol had an ICER of $3214.06 per additional aSF, which was more favorable than dexmedetomidine (ICER: −$9222.85). Sensitivity analysis showed that ICER values were most sensitive to the success rates of each sedation regimen, followed by the reimbursement rate for anesthesiologist-administered sedation. CEACs confirmed that triclofos sodium and propofol were the most favorable, while midazolam and general anesthesia were less favorable. The probability of cost-effectiveness for propofol varied from 0 to 51.6%, and for triclofos sodium, it ranged from 100 to 38.9%. Conclusion: Propofol sedation administered by anesthesiologists demonstrated superior cost-effectiveness compared to dexmedetomidine and midazolam sedation administered by non-anesthesiologists, primarily due to higher success rate and lower reimbursement rate for sedation procedures by anesthesiologists. Increasing reimbursement for anesthesiologist-administered sedation may be justifiable, though further real-world validation is needed.