JULY 24, 2025
Originally published by our sister publication Anesthesiology News
ORLANDO, Fla.—Three speakers at the 2025 annual meeting of the Society for Pediatric Anesthesia (SPA) detailed numerous notable papers published in 2024. This article summarizes two papers each from the journals Anesthesiology, Anesthesia & Analgesia and Pediatric Anesthesia, presented by editors of the respective journals.
Originally published by our sister publication Anesthesiology News
ORLANDO, Fla.—Three speakers at the 2025 annual meeting of the Society for Pediatric Anesthesia (SPA) detailed numerous notable papers published in 2024. This article summarizes two papers each from the journals Anesthesiology, Anesthesia & Analgesia and Pediatric Anesthesia, presented by editors of the respective journals.
“This is a study that most of you have heard of or been involved with,” said David Faraoni, MD, PhD, a cardiac anesthesiologist at Boston Children’s Hospital and faculty member at Harvard Medical School.
According to the associate editor of Anesthesiology, this ongoing study compares whether providing low-dose sevoflurane/dexmedetomidine/remifentanil is better for global cognitive function than standard-dose sevoflurane at age 3 years, when given to children under 2 years of age for an expected two hours or more. It includes 455 children treated at 20 health centers in Australia, Italy and the United States.
The global cognitive function results have not been published. Faraoni presented the results of a secondary analysis that compared various short-term outcomes (measured at five days after surgery) between the two anesthesia regimes. Outcomes included rates of hypotension and bradycardia, need for pain medication, and morbidity and mortality. Although the data were not sufficient to link every outcome to the effects of the different anesthesia options, available data showed no difference in short-term outcomes. That said, bradycardia was more common in the low-dose anesthesia group, which Faraoni attributed to the use of remifentanil and dexmedetomidine. The time to discharge, and morbidity and mortality rates, were similar in both groups.
“Broadly, we can say the two groups were doing about the same,” Faraoni said.
“In this prospective randomized study, investigators evaluated methadone as a long-duration opioid with a rapid onset for tonsillectomies,” Faraoni said. Methadone use (n=40) was compared with a control of fentanyl use (n=20) for the seven days after surgery, in children from 3 to 17 years of age. The hypothesis was that starting with methadone for pain management would reduce overall opioid use.
The study’s small sample size, which Faraoni noted is common in pediatric trials, makes definitive interpretations difficult because of a lack of statistical significance. But the data do suggest that, as predicted, methadone decreased opioid use after a tonsillectomy.
Total seven-day opioid use, in median oral morphine equivalents per kilogram of body weight, was 1.5 (IQR, 1.2-2.1) in children who received fentanyl, 0.9 (IQR, 0.1-1.4) in children who received methadone 0.1 mg/kg (P=0.045), and 0.5 (IQR, 0-1.4) in those who received methadone 0.15 mg/kg (P=0.023).
This study compared complication rates between axillary and femoral arterial line placement in children undergoing cardiac surgery in whom peripheral placement was not feasible. All surgeries were performed at Boston Children’s Hospital. Complications included loss of pulse and vascular compromise.
“Pulse loss was pretty rigorously defined as the absence of a pulse by a Doppler analysis,” said James A. DiNardo, MD, a cardiac anesthesiologist at Boston Children’s Hospital and a professor of anesthesiology at Harvard Medical School. The authors found significantly less pulse loss and vascular compromise in children who had an axillary arterial line placement, compared with femoral placement.
Rates of arterial and femoral line placement at Boston Children’s are currently roughly equal, noted DiNardo, the pediatric anesthesiology section editor for Anesthesia & Analgesia. Historically, femoral placement was far more common. There are some technical considerations involved in placement of axillary arterial lines, which DiNardo noted could be accompanied by a learning curve.
This retrospective review evaluated complications from 1,068 femoral arterial lines and 195 axillary arterial lines. Researchers found that children with axillary lines experienced lower rates of vascular compromise (6.2% vs. 19.9%; P<0.001), pulse loss (2.1% vs. 9.5%; P<0.001) and thrombus or flow abnormalities (14.3% vs. 81.1%; P=0.001) than with femoral lines.
“This is a really nice study looking at the impact of sugammadex introduction on the use of neuromuscular blockade and on endotracheal intubation,” DiNardo said. The study’s time period was 2014 to 2022. This enabled researchers to compare patterns in pediatric surgeries before the availability of the neuromuscular blocker sugammadex (2014-2016), as sugammadex was coming widely into practice (2017-2019), and as its use was widely established in practice (2020-2022).
This retrospective analysis from the University of Michigan assessed 25,638 anesthetics. The authors found a significant increase in use of neuromuscular blockade as a component of general anesthesia as sugammadex became widely available. Notably, over the same period, there was a decline in endotracheal intubation in favor of supraglottic airways.
“We introduce a new drug and it changes the way we deliver an anesthesia. Is that a good thing or a bad thing?” DiNardo asked, adding that the answer is unclear.
Compared with 2014-2016, researchers found that the likelihood of using a neuromuscular blockade increased from 2017 to 2019, after sugammadex was introduced (odds ratio [OR], 1.55; 95% CI, 1.38-1.75). There was a further increase from 2020 to 2022, as sugammadex use was established (OR, 5.62; 95% CI, 4.96-6.37).
“Remimazolam was approved for use in adults in 2020. It’s not approved in children yet, but it will be coming,” said Justin Lockman, MD, MSED, FAAP, a pediatric anesthesiologist and an intensivist at Children’s Hospital of Philadelphia (CHOP) and a professor of clinical anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine, also in Philadelphia.
Lockman, the education editor for Pediatric Anesthesia, said remimazolam offers a combination of remifentanil pharmacodynamics and benzodiazepine pharmacology. It is used for procedural sedation. He is currently in discussions about adding remimazolam to the formulary at CHOP, to study its effects in children. Meanwhile, he recommends that readers consult this review article to better understand how remimazolam works and its potential uses.
The review summarizes case reports of remimazolam use in children, its pharmacologic properties and dosing parameters when used in pediatrics.
This article addresses perioperative management of children (and others) with type 1 diabetes, with a focus on helping anesthesia providers use insulin pumps and continuous glucose monitors most effectively to regulate glucose levels. Target glucose is from 90 to 180 mg/dL, with treatment above 250 or below 70 for most patients, Lockman said, with a minimum of hourly fingerstick glucose checks currently recommended. Glucose or dextrose should be coadministered with any insulin.
“This is a really nice review of the technology. There have been enormous advances in technology, particularly for people with type 1 diabetes, in the last five years,” Lockman said, referencing tubeless “all in one” insulin pumps and smartphone-connected continuous glucose monitors.
The article guides pediatric anesthesiologists on the importance of coordinating care during the perioperative period, between the anesthesiologist, proceduralist, parent and child. It also discusses how to monitor blood glucose and appropriately administer basal insulin.
By Marcus A. Banks
DiNardo, Faraoni and Lockman reported no relevant financial disclosures.
