Anesthesia Research

Providing safe pediatric anesthesia during humanitarian cleft and maxillofacial surgery is particularly challenging because evidence-based perioperative care must be adapted to resource-limited environments while maintaining internationally recognized standards of patient safety. This educational review synthesizes current evidence across the major phases of pediatric perioperative anesthesia, including patient selection, fasting, airway management, regional and multimodal analgesia, fluid therapy, intraoperative monitoring, emergence, and postoperative care. International clinical practice guidelines, consensus statements, reviews, and relevant clinical studies were critically considered alongside multidisciplinary humanitarian experience. Based on this synthesis, current evidence was translated into an evidence-informed standardized perioperative protocol specifically designed for humanitarian cleft and maxillofacial surgery in low-resource settings. The proposed framework integrates structured perioperative assessment, individualized airway and extubation strategies, multimodal analgesia, appropriate physiological monitoring, multidisciplinary communication, and adaptation to locally available resources. Rather than replacing existing international recommendations, the protocol aims to facilitate their practical implementation through a reproducible and adaptable perioperative pathway. This framework may support greater consistency and safety in pediatric anesthesia delivery during humanitarian surgical missions while providing a basis for education, quality improvement, and future research. Prospective validation is required to assess its feasibility, adherence, clinical outcomes, and acceptability across different humanitarian settings.

Background/Objectives: As demand for pediatric magnetic resonance imaging (MRI) continues to increase, anesthesia assistance is often required for children who cannot cooperate. This study described the incidence and causes of same-day cancellations and evaluated the impact of a Preoperative Evaluation Clinic (PEC) for children undergoing elective MRI under sedation or general anesthesia at a tertiary-level children’s hospital. Methods: This single-center retrospective study reviewed children scheduled for elective anesthesia-assisted MRI at the Montreal Children’s Hospital between January 2013 and December 2019. Same-day cancellations were included, and reasons for cancellation were categorized as preventable, possibly preventable, or unpreventable. A pilot anesthesia-led PEC operated from January 2018 to December 2019, and its effect on same-day MRI cancellations was assessed. Results: Of 4518 MRIs scheduled between 2013 and 2019, 549 (12.2%) were canceled on the same day, with the annual cancellation rate declining from 14.6% in 2013 to 9.4% in 2019. Possibly preventable patient illness and no-shows accounted for 61% of cancellations. Of 1383 MRIs scheduled in 2018–2019, 602 (43.5%) were assessed in the PEC and 781 (56.5%) were not. Same-day cancellation occurred in 131/1383 (9.5%) cases: 48/602 (8.0%) in the PEC group versus 83/781 (10.6%) in the non-PEC group (p = 0.07). PEC attendance was associated with fewer no-shows (1.0% versus 2.8%, p = 0.017). Conclusions: Patient illness and no-shows were the main causes of same-day cancellations. PEC attendance was associated with fewer no-show cancellations, although this trend cannot be attributed to a specific intervention and should be interpreted with caution. Alternative cost-effective interventions should be explored to further reduce same-day MRI cancellations.

Background: Intraprocedural hypoxemia remains a common challenge during open-tube jet ventilation via rigid bronchoscopy, potentially necessitating conversion to alternative airway strategies. We evaluated patient factors associated with hypoxemia and the feasibility of a tube-in-tube salvage utilizing the positive-pressure ventilation technique. Methods: A retrospective single-center review of rigid bronchoscopies was performed between January 2024 and July 2026. Refractory hypoxemia was defined as oxygen saturation < 90% for >120 s or the need to abandon jet ventilation for an alternative ventilation strategy. Patient demographics, procedural characteristics, and airway management outcomes were analyzed. Results: A total of 235 rigid bronchoscopies were reviewed, of which 37 (15.8%) were complicated by refractory hypoxemia. Patients developing hypoxemia had higher body mass index (30.4 ± 7.6 vs. 26.2 ± 11.0 kg/m², p = 0.006) and longer procedure duration (76.4 ± 35.1 vs. 48.1 ± 29.9 min, p < 0.001) compared with non-hypoxemic patients. Among hypoxemic patients, 12 underwent tube-in-tube salvage and 25 received alternative management. Tube-in-tube salvage successfully restored oxygenation without airway conversion in all patients (12/12, 100%). In contrast, 12 of 25 patients (48%) managed without tube-in-tube salvage required conversion to an alternative airway strategy (p = 0.003). Conclusions: Refractory hypoxemia remains a common occurrence during open-tube jet ventilation and was associated with higher BMI and longer procedure duration. Tube-in-tube salvage utilizing positive-pressure ventilation was feasible, avoided additional airway manipulation, and allowed for the continuation of planned procedures. Larger, prospective studies are needed to further evaluate safety and efficacy.