Search Results (307)

Although radiotherapy is a cornerstone in the management of several pediatric malignancies, its administration in children poses unique anesthetic challenges. Unlike adults, pediatric patients, particularly younger children, often require repeated sedation or general anesthesia to ensure immobility and reduce psychological distress during daily treatment sessions that may extend over several weeks. This narrative review summarizes current evidence on anesthetic strategies for children undergoing radiotherapy, focusing on clinical indications, pharmacological approaches, safety considerations, and organizational aspects. We discuss the main sedation and anesthesia techniques used in non-operating room anesthesia (NORA) settings, including deep sedation with midazolam, propofol, ketamine, and dexmedetomidine, as well as general anesthesia with laryngeal mask airway management. Particular attention is given to the cumulative effects of repeated anesthetic exposure, airway management challenges in remote radiation environments, and the risk of respiratory and hemodynamic complications. The review also highlights the importance of individualized, protocol-driven management, rapid recovery strategies, and continuous remote monitoring systems. Non-pharmacological interventions and audiovisual-assisted techniques are also discussed as potential strategies to reduce anesthesia requirements in selected patients. A multidisciplinary approach involving anesthesiologists, radiation oncologists, nurses, psychologists, and technical staff is essential to optimize safety, treatment adherence, and overall quality of care. Tailored anesthetic management, supported by standardized protocols and specialized pediatric expertise, remains crucial to balancing procedural efficacy with short- and long-term safety in this vulnerable population. Full article

Background: Cardiopulmonary bypass (CPB) is an essential technique for cardiac surgery but significantly increases the risk of perioperative neurological complications. Electroencephalography (EEG) enables real-time monitoring of brain function and provides sensitive biomarkers for early detection of cerebral injury. However, a systematic synthesis of how CPB-related physiological, pharmacological, and technical factors influence EEG signals, and how these insights can be integrated into clinical decision-making, is still lacking. Objective: To systematically review the effects of temperature management, mean arterial pressure (MAP), hemodilution, anesthetic agents, embolization, and systemic inflammatory response during CPB on EEG parameters (including frequency bands, Bispectral Index (BIS), quantitative EEG metrics such as burst suppression ratio (BSR), spectral edge frequency (SEF), etc.), and to evaluate the associations between EEG changes and postoperative delirium (POD) and stroke. Methods: Following the PRISMA 2020 guidelines, we searched PubMed, Web of Science, and related databases for original English-language articles published between February 1974 and September 2025. Inclusion criteria: adult patients (≥18 years) undergoing cardiac surgery with CPB and intraoperative EEG monitoring (raw or processed). Exclusion criteria: reviews, case reports, animal studies, pediatric populations, and articles with inaccessible full texts. Two reviewers independently screened the literature and extracted data; a narrative synthesis was performed. Results: Fifty-one studies were included. Main findings: (1) Hypothermia: BIS decreases linearly with temperature (≈1.12 units/°C); electrocerebral silence occurs during deep hypothermic circulatory arrest; EEG recovery dynamics during rewarming predict POD. (2) MAP and cerebral perfusion: The rate of MAP decline (≥0.66 mmHg/s) is a stronger predictor of EEG abnormalities than the absolute MAP value; under fixed pump flow, some patients exhibit coexisting cerebral overperfusion and metabolic suppression. (3) Hemodilution: Maintaining hemoglobin ≥9.4 g/dL prevents EEG slowing; a drop below 9.2 g/dL significantly increases the risk of slowing. A ≥10% decrease in regional cerebral oxygen saturation (rSO₂) is associated with a 1.5-fold increased risk of burst suppression. (4) Anesthetic agents: Propofol maintains flow-metabolism coupling, and BSR reflects deep anesthesia better than BIS; sevoflurane and isoflurane impair autoregulation and suppress EEG. (5) Embolization and inflammation: EEG epileptiform discharges increase the risk of POD five-fold; a decrease in LIR predicts stroke (AUC 0.771) and POD (AUC 0.779); persistent EEG changes increase the risk of POD 2.65-fold. Conclusions: CPB-related factors affect EEG signals through distinct mechanisms, and specific EEG patterns (slowing, burst suppression, asymmetry, epileptiform discharges) are significantly associated with postoperative neurological complications. Multimodal monitoring (EEG + cerebral oximetry + hemodynamics) with clear intervention thresholds facilitates individualized brain protection. Future interventional studies using real-time EEG feedback are needed to confirm improvements in long-term neurological outcomes. Full article

This study compared the wound-healing response and osteogenic gene expression profile of osteoblasts exposed to pediatric-equivalent concentrations of dexmedetomidine (DXMT) and propofol (POF). Human osteoblast-like SAOS-2 cells were assigned to control, low- and high-dose DXMT and POF groups based on pharmacokinetically derived free-drug levels. Scratch-wound closure was quantified over 24 h, and expression of osteogenesis- and cytoskeleton-related genes (RANKL, RUNX2, SP7, BMP2, VIM, VCL, OCN, ALP) was measured by SYBR Green quantitative Polymerase Chain Reaction (qPCR). Normality was assessed using the Shapiro–Wilk test, and group differences were analyzed with two-way ANOVA followed by Tukey’s multiple comparisons test (p < 0.05). All groups demonstrated complete scratch closure by 24 h, with no differences at 6 h. At 18 h, POF did not differ from the control, whereas DXMT significantly accelerated closure at both doses in a dose-dependent fashion. High-dose DXMT significantly increased VIM (3.95 ± 3.12, p = 0.0144) and BMP2 (2.28 ± 0.70, p = 0.0002) expression, while RUNX2, SP7, and RANKL remained comparable to controls. ALP (1.68 ± 0.40, p = 0.0005) and OCN (3.31 ± 0.35, p = 0.0108) were significantly elevated only in the high-dose DXMT group, whereas POF showed no significant effects. At clinically relevant concentrations, DXMT was associated with enhanced scratch closure and increased expression of selected osteogenesis- and cytoskeleton-related genes in SAOS-2 cells, whereas POF showed limited effects under the tested conditions. These findings suggest that DXMT may influence early in vitro cellular responses relevant to bone healing and should be further validated in functional differentiation models and in vivo studies. Full article

Background/Objectives: Few studies focus on essential information and training for responsible caregivers in the operating theatre (OT). Our study explored challenges, opportunities and critical information for caregivers close to the child until induction, drawing on the experiences of nurses and caregivers. Methods: A mixed-method exploratory sequential design was adopted in the OT and surgery wards of a maternal and child health hospital in Italy (2021–2023). Results: Twelve nurses were involved in 2 focus groups. The content analysis yielded 3 themes and 6 subthemes. Two questionnaires were developed for nurses and caregivers based on qualitative findings. The quantitative phase included 25 nurses and 140 caregivers. Results from the quantitative strand confirm findings from the qualitative strand. However, discrepancies in information needs highlight gaps. Conclusions: Optimizing family comfort and workflows in the OT depends on caregivers’ awareness of their role near the child, emphasizing mindful presence and awareness of their body movements—watching, touching and fidgeting. Full article

Early childhood caries (SECC) in children aged 3–4 years is a high-burden condition with consequences that extend beyond the dentition, including pain, infection, sleep disturbance, impaired nutrition, disrupted family functioning, and diminished quality of life. In contemporary pediatric practice, 38% silver diamine fluoride (SDF) and other minimally invasive approaches are widely used to stabilize disease while behavior matures, preventive strategies are intensified, or access to definitive care is secured. This perspective argues that SDF should be conceptualized not as a standalone solution, but as an evidence-supported interim stabilization strategy embedded within a defined, goal-directed care pathway. Its use is most appropriate when framed as a means of buying time under clear clinical intent, particularly in cases where teeth are expected to remain functional for years, symptoms are present, structural integrity is compromised, or follow up is uncertain. Although clinical guidelines and systematic reviews support SDF for arresting cavitated lesions in primary teeth, current evidence does not support its use as a universal long-term treatment for severe disease. Real-world data suggest that many SDF-treated teeth require additional intervention within approximately 2 years, and that delays to definitive care—including treatment under sedation or general anesthesia when indicated—are often relatively short. In response, this paper proposes a practical bridge-to-destination framework grounded in three principles: explicit treatment intent, child-centered outcomes, and predefined exit criteria to ensure a timely transition to definitive dental care. Rather than discouraging SDF use, this approach seeks to optimize its role within a continuum of dental care, emphasizing proportionality, transparency, and durable outcomes for children. Full article

Background: Regional anesthesia is a fundamental aspect of contemporary perioperative care. However, variability in practice, incomplete documentation, and inconsistent safety protocols continue to pose preventable risks. Although there are international checklist models for regional anesthesia and perioperative safety such as those developed by ASRA, ESAIC, and the WHO, Italy does not have a nationally endorsed checklist that is consensus-based and specifically tailored to local terminology, workflows, and legal requirements. Methods: To address this gap, we developed an evidence-based Locoregional Anesthesia Checklist (LRA Checklist) using established frameworks for healthcare checklist design. The development process included a needs assessment through a national survey of ESRA Italy members, a review of existing models, item drafting, expert consensus, and endorsement by the Board. We assessed content validity through a modified Delphi process involving 15 experts from the ESRA Italian Chapter Board. Additionally, we created a theoretical impact model to estimate the potential organizational and economic effects of implementing the checklist, using baseline institutional parameters. Results: Consensus was achieved for all checklist domains after two Delphi rounds, with minor edits to improve clarity, usability, and clinical relevance. The theoretical model indicates that adopting checklists may help reduce preventable complications, improve workflow, enhance documentation and traceability, and provide overall benefits to institutions in various scenarios. Conclusions: In conclusion, the LRA Checklist is a structured, consensus-based tool tailored for the Italian context, aimed at promoting safer and more standardized practices in regional anesthesia. To our knowledge, no prior Italian national consensus or checklist specifically dedicated to regional anesthesia has been formally published. Prospective multicenter studies are necessary to confirm its effectiveness in real-world settings and to quantify both clinical and economic outcomes. Full article

Background: Dental care for non-cooperative patients is a major clinical and organizational challenge, particularly in individuals with intellectual or neurodevelopmental disabilities and in patients with severe dental anxiety or phobia. When behavioral techniques are insufficient, conscious or deep sedation or general anesthesia may be required, but practical guidance on selection and care pathways remains fragmented. Methods: We combined a retrospective observational analysis from a single Italian academic center with a narrative review of the international literature. Forty-one sedation-assisted dental sessions were included. Demographics, indication for non-cooperation, sedation regimens, procedures, completion rates, and adverse events were descriptively analyzed. Results: The cohort included pediatric and adult patients; non-cooperation was mainly related to disability/neurodevelopmental conditions or severe dental phobia. Benzodiazepine-based oral or intravenous sedation, sometimes combined with low-dose propofol, enabled completion of all planned procedures without major adverse events or conversion to general anesthesia. The literature supports general anesthesia for profound non-cooperation or extensive treatment needs, but availability and waiting lists limit access; sedation is effective for selected cases with appropriate organizational support. Conclusions: An individualized stepped-care model integrating behavioral management, sedation, general anesthesia, and structured preventive recall may optimize access and outcomes within the Italian context and strengthen long-term post-treatment attendance. Full article

Background: General anesthesia (GA) plays a key role in pediatric dentistry by enabling comprehensive dental treatment in children who cannot be adequately managed using conventional behavioral techniques, local anesthesia, or sedation. While previous reviews have primarily focused on safety outcomes and adverse events, less attention has been given to patterns of GA utilization and their broader clinical and public health implications. Objective: The objective was to synthesize and critically analyze contemporary evidence on utilization patterns, clinical indications, and treatment characteristics associated with GA in pediatric dentistry and to interpret variability in GA use as a clinical and health-system indicator. Methods: A systematic review with qualitative synthesis was conducted in accordance with PRISMA 2020 guidelines. Electronic searches were performed in EBSCOhost, Scopus, and the Cochrane Library to identify observational studies published between 2015 and 2025 reporting clinical data on pediatric dental treatment under GA. Results: Twenty-two observational studies met the inclusion criteria. Severe early childhood caries was the most frequently reported indication for GA, followed by behavioral management difficulties and treatment of children with special health care needs. Reported utilization rates varied widely across healthcare systems. Conclusions: GA remains an essential modality for managing complex pediatric dental cases; however, variability in utilization appears to reflect differences in preventive access, disease burden, and health-system organization. Interpreting GA use as a healthcare utilization indicator may support improved preventive strategies and policies aimed at reducing repeated GA exposure in vulnerable pediatric populations. Full article

Background/Objectives: Tidal volume is determined by height and sex in adults under mechanical ventilation, and it serves as the foundation for implementing a lung-protective ventilation strategy. In children, tidal volume is often calculated based on actual body weight, without established guidelines regarding the predictors of lung volume. The aim of this study was to identify the key predictors of lung volume in children aged 0–5 years. Methods: This retrospective study involved 51 children aged 0–5 years who underwent chest computed tomography (CT) and surgery under general anesthesia between 2014 and 2024. The total lung volume was calculated using three-dimensional segmentation of the CT images. Linear regression models were used to assess predictors, including height, weight, age, sex, and body mass index (BMI). Model performance was evaluated using the adjusted R-squared and Akaike Information Criterion (AIC). Bootstrap validation with 2000 iterations was used to validate model reliability. Results: Height was the strongest predictor of lung volume (adjusted R-squared: 0.5621), and it showed a collinearity with age. The final model included age and sex as the covariates. The Bootstrap validation confirmed the model’s reliability. Conclusions: Age and sex are key predictors of the CT-derived total lung volume in children aged 0–5 years. Further studies are required to validate these findings. In addition, research is needed to derive and validate a tidal volume equation based on these predictors and assess the influence of this equation on clinical outcomes such as atelectasis, oxygenation, and inflammatory markers in pediatric surgery. Full article

Background: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis causes significant postoperative pain and high opioid requirements. Methadone, with dual μ- and κ-opioid agonism and NMDA antagonism, provides long-acting analgesia and may reduce perioperative opioid use. This study evaluated whether perioperative low-dose methadone (0.1 mg/kg) improves postoperative pain and opioid outcomes after pediatric PSF. Methods: In this single-center retrospective cohort study (January 2019–June 2023), pediatric patients <23 years old undergoing PSF were categorized by perioperative methadone exposure (intraoperative and/or postoperative) versus no methadone. The primary outcome was total postoperative opioid consumption (morphine milligram equivalents per kilogram, MME/kg) over postoperative days (POD) 0–3. Secondary outcomes were average daily pain scores and hospital length of stay (LOS). Inverse probability weighting (IPW) adjusted for age, sex, and protocol period. Results: A total of 339 patients (51% no methadone, 49% methadone; mean age 14.6 ± 2.5 years; 76% female) were analyzed. Methadone patients had longer anesthesia (392 vs. 372 min, p = 0.042) and surgery times (287 vs. 266 min, p = 0.01). IPW-adjusted associations show postoperative opioid use was significantly higher in the methadone group on POD 0 (median 2.5 vs. 2.1 MME/kg in no methadone group; p = 0.005). No significant differences were found in postoperative average pain scores (e.g., mean NRS: 2.3 vs. 2.5 on POD 0, p = 0.12) and LOS (3.3 vs. 3.1 days, p = 0.38) between methadone group and no methadone group. Discussion: Perioperative methadone provided similar analgesia for pain management and recovery without prolonging hospitalization, despite higher early opioid use on POD 0. Retrospective design limits causal inference, and residual confounding may persist despite propensity score-based adjustments. Further prospective trials are required to establish safety and dosing. Conclusions: In this retrospective cohort, perioperative low-dose methadone was associated with higher early postoperative opioid use but no significant differences in pain scores or length of stay compared with standard regimens. Methadone did not demonstrate an opioid-sparing effect in this real-world setting. Prospective studies are needed to better define its role and safety in pediatric posterior spinal fusion. Full article

Background: Laryngospasm is defined as glottis closure due to reflex constriction of the laryngeal muscles. It is one of the most common complications following pediatric anesthesia that can lead to hypoxemia, bradycardia, or aspiration. Laryngospasm following tracheal extubation has different reasons: presence of secretions, foreign body in the airway, or pain at the site of surgery. Propofol is usually used as an induction or maintenance agent. However, its use with the subhypnotic dose (0.5 mg/kg) is increasing nowadays for reducing the incidence of laryngospasm. This systematic review and meta-analysis aim to assess the efficacy of subhypnotic propofol in reducing the incidence of laryngospasm and respiratory complications in children following tonsillectomy or adenotonsillectomy and before extubation. Methods: We systematically searched the following databases: PubMed, Cochrane Library, Scopus, and Web of Science. Studies were included if they used propofol with a low dose (0.5 mg/kg) following tonsillectomy and before extubation. Both Randomized Controlled Trials (RCTs) and cohort studies published up until 27 December 2025 were included. We used the R software for statistical analysis. We employed a random-effects model for the analysis. Continuous outcomes were analyzed as mean differences (MD) and dichotomous data as risk ratios (RR), with 95% confidence intervals (CI). Heterogeneity was assessed using I² statistics. Results: Our review included four RCTs and one prospective cohort study with 593 participants. Our analysis showed that propofol was significantly associated with a low incidence of laryngospasm (RR = 0.25, 95% CI 0.13–0.49), cough (RR = 0.08, 95% CI 0.01–0.62), and agitation (RR = 0.15, 95% CI 0.03–0.72) compared with the control group. However, there were no significant differences regarding laryngeal occlusion (RR = 0.70, 95% CI 0.20–2.46), cyanosis (RR = 1.13, 95% CI 0.14–9.43), stridor (RR = 1.38, 95% CI 0.76–2.50), and the duration of surgery (MD = 1.81, 95% CI −0.74 to 4.36). Conclusions: Our findings state that propofol had a lower significant incidence of laryngospasm than the control. Trial sequential analysis for laryngospasm indicated that evidence is conclusive. However, regarding the other outcomes, the evidence is still inconclusive, which suggests the need for future large-scale RCTs with larger sample sizes to validate these findings. Full article

Background: Dental fear and anxiety are highly prevalent in children, resulting in avoidance or incomplete dental treatment; sedation emerges as a possible behavioral management strategy. This umbrella review aimed to provide a structured and critical synthesis of the available knowledge on sedative single-agent efficacy and routes of administration employed for achieving sedation (excluding deep sedation/general anesthesia) during dental procedures in children for behavior management, as well as to evaluate acceptability and satisfaction for child, caregiver, and provider, and to assess the influence of clinical setting and provider. Methods: In line with the PRISMA statement, the protocol was registered on PROSPERO (CRD420251043738), and 18 systematic reviews were included and synthesized qualitatively. Results: Single-agent sedation was safe and effective for managing behavior in children during dental procedures, with midazolam and nitrous oxide being the most studied agents. Different routes of administration showed distinct characteristics in onset, recovery time, adverse effects and cooperation, while agent selection appeared influenced by clinical setting and provider type. However, data on acceptability and satisfaction from children, caregivers, and providers remains limited. Conclusions: Evidence suggests potential effectiveness of selected agents and routes in appropriately monitored settings, but data heterogeneity precludes strong comparative recommendations. Further studies are therefore needed to address the existing gaps in pediatric dental sedation. Full article

Background/Objectives: Postoperative delirium is an acute condition commonly seen in pediatric patients. It is often observed in intensive care units for patients undergoing general anesthesia. Characteristic symptoms include disturbances of consciousness, attention, perception, or disorientation. The occurrence of delirium can be assessed using the CAPD and PAED scales. Methods: A single-center observational cohort studyof the 2022–2024 results was conducted. A total of 89 patients of the Pediatric Anesthesiology and Intensive Care Unit undergoing procedures under general anesthesia were included in this study. The state of delirium just after the recovery from anesthesia was assessed using the CAPD and PAED scales. Results: A total of 60% of patients experienced delirium taking the results according to the CAPD scale, 39% according to the PAED scale. A score indicating delirium according to both the CAPD and PAED scales was recorded in 21% of the patients examined. The results of the correlation analyses indicate a strong relationship between the CAPD and PAED scales. The feature analysis indicated there was a correlation between the occurrence of delirium and chronic disease. One of the confirmed risk factors for the development of postoperative delirium in children is postoperative pain. The experience of postoperative delirium is associated with the observation of negative postoperative behavioral changes in children within 7 days of hospital discharge. Conclusions: The correlation analysis showed a significant positive relationship between CAPD scale and PAED scale. The feature analysis indicated a relationship between CAPD scores and the existence of chronic diseases. Full article

Background: Remimazolam tosilate is a novel, ultra-short-acting benzodiazepine. To address the unmet clinical need for safe and controllable general anesthetic options in children and adolescents, both top-down (i.e., population pharmacokinetics—PopPK) and bottom-up (i.e., physiologically based PK—PBPK) modeling approaches were combined to leverage their respective strengths for dose selection in children and adolescents aged 3–18 years. Methods: Pooled PK data from adult studies were used to develop and verify the adult PopPK and PBPK models. The PopPK model included allometric scaling to describe body weight effects, while the PBPK modeling incorporated the age-dependent physiological and metabolic ontogeny. Potential covariates and intrinsic factors influencing remimazolam exposure were assessed. Both models were then applied to simulate PK and derive exposure metrics in 3–18-year-old children and adolescents. The predictions from both approaches were used to support pediatric dose selection using an adult-matching exposure approach. Results: The PopPK and PBPK model simulations yielded consistent exposure predictions and converged on the same recommended dosing regimens for the pediatric population, providing mutual confirmation of model reliability. Both models indicated that the proposed regimens of remimazolam would achieve systemic exposures in children and adolescents (3–18 years) comparable to those in adults receiving an induction dose of 0.3 mg/kg followed by maintenance infusions of 1.0 or 3.0 mg/kg/h. Two pediatric dosing regimens were recommended: 1. Lower dose group: induction 0.2 mg/kg, initial maintenance 1.0 mg/kg/h, titratable as needed, with a maximum rate of 3.0 mg/kg/h (up to 4.0 mg/kg/h for individuals ≤ 30 kg). 2. Higher dose group: induction 0.3 mg/kg, initial maintenance 2.0 mg/kg/h, titratable as needed, with a maximum rate of 3.0 mg/kg/h (up to 4.0 mg/kg/h for individuals ≤ 30 kg). The model-informed dosing regimens have received regulatory approval from the Center for Drug Evaluation (CDE) in China and are currently being evaluated in an ongoing clinical trial. Conclusions: The integrated PopPK–PBPK approach supports evidence-based dosing recommendations of remimazolam for general anesthesia in children and adolescents aged 3–18 years and provides a reference for dose selection in future clinical studies. Full article

Introduction: Postoperative delirium, including emergence agitation, is recognized in the post-anesthesia care unit as a fluctuating disturbance of attention and cognition. The current evidence examined suggests that both anesthetic agents and postoperative pain intensity may influence the risk of delirium. The aim of this review is to discuss the significance of pharmacological agents used during anesthesia and the relationship between the intensity of postoperative pain and the occurrence of postoperative delirium in patients undergoing surgical procedures, regardless of age. Methods: A scoping review was conducted from December 2024 to December 2025. The articles identified in each search were limited to those published between 2015 and 2025. Results: Agents such as dexmedetomidine, remimazolam, and magnesium sulfate were examined in the included trials and were reported to be associated with reducing the incidence and severity of postoperative delirium, particularly in pediatric and elderly patients. Analysis of clinical trial outcomes conducted in pediatric populations undergoing various surgical procedures suggests that dexmedetomidine (administered intranasally and intravenously) and alfentanil were associated with lower incidence and severity of emergence delirium compared to standard care or other agents (e.g., midazolam). Higher doses of dexmedetomidine (2 µg/kg) were reported to be associated with improved postoperative analgesia and reduced agitation, without prolonging recovery time or causing serious adverse effects. Propofol, due to its rapid metabolism, was suggested to contribute to shorter emergence times; however, its impact on cognitive function requires further investigation. Additionally, there remains a lack of agreed-upon and/or validated tools and strategies for pain assessment in patients experiencing delirium. Conclusions: The current evidence examined suggests that the use of intranasal dexmedetomidine at appropriate doses may be associated with reduced postoperative pain and agitation without prolonging recovery time or increasing the risk of serious adverse events. Hydromorphone was reported in the included trials to be associated with better postoperative pain control than sufentanil, whereas remimazolam, although associated with reduced delirium incidence in some trials, did not influence the length of stay in the post-anesthesia care unit. Magnesium sulfate, although not significantly affecting the incidence of delirium, was associated with alleviation of postoperative symptoms such as pain and insomnia in adult patients. Ketamine, while commonly used for analgesic therapy, did not demonstrate a consistent association with delirium prevention and, in some studies, was associated with increased neuropsychiatric events. Further research is required to more precisely define optimal perioperative delirium prevention protocols. Full article