The Current State of Pediatric Cardiac Anesthesiology Staffing in the United States.

Background: The population of patients with congenital heart disease has grown, but the supply of pediatric cardiac anesthesiologists has not kept pace. The Pediatric Anesthesia Leadership Council (PALC) and the Congenital Cardiac Anesthesia Society (CCAS) formed a task force to evaluate the current state of the specialty of pediatric cardiac anesthesia, including staffing, work environment, education, compensation, and career development.

Methods: Five task force working groups developed survey questions that explored 5 different aspects of a pediatric cardiac anesthesiologist's career.

Clinical implementation of the 3D 4K exoscope (Orbeye™) in reconstructive head and neck surgery.

Purpose: To assess the clinical utility of the 3D 4K exoscope for reconstructive head and neck surgery.

Methods: This retrospective study analyzed surgical details and complications with the use of the 3D 4K exoscope for microvascular reconstruction at a high-volume Department of Oral and Maxillofacial Surgery, compared to the use of a 2D microscope. Patients with oral cancer undergoing microvascular reconstruction were categorized into two cohorts based on the intraoperative use of the 3D 4K exoscope (Orbeye™, Olympus, Tokyo, Japan) or a conventional microscope (ZEISS S8 - OPMI Vario, Carl Zeiss AG, Oberkochen, Germany; Leica M680, Leica Mikrosysteme Vertrieb GmbH, Wetzlar, Germany) during a six-month study period, respectively.

Electroencephalographic Indices for Clinical Endpoints during Propofol Anesthesia in Infants: An Early-phase Propofol Biomarker-finding Study.

Background: Unlike expired sevoflurane concentration, propofol lacks a biomarker for its brain effect site concentration, leading to dosing imprecision particularly in infants. Electroencephalography monitoring can serve as a biomarker for propofol effect site concentration, yet proprietary electroencephalography indices are not validated in infants. The authors evaluated spectral edge frequency (SEF95) as a propofol anesthesia biomarker in infants.

Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project.

Background: Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia.

Quantitative electroencephalogram in term neonates under different sleep states.

Electroencephalogram (EEG) can be used to assess depth of consciousness, but interpreting EEG can be challenging, especially in neonates whose EEG undergo rapid changes during the perinatal course. EEG can be processed into quantitative EEG (QEEG), but limited data exist on the range of QEEG for normal term neonates during wakefulness and sleep, baseline information that would be useful to determine changes during sedation or anesthesia. We aimed to determine the range of QEEG in neonates during awake, active sleep and quiet sleep states, and identified the ones best at discriminating between the three states.

Why is system 1/system 2 switching affectively loaded?

Why are only some occasions of system 1 to system 2 switching affectively loaded? This commentary not only draws attention to this neglected phenomenon, but also shows how research in philosophy and the social and cognitive sciences sheds light on it, doing so in ways that may help answer some of the open questions that De Neys's paper highlights.

Are we virtuously caring or just anxious?

According to Grossmann, the high levels of cooperation seen in humans are the result of a "virtuous caring cycle" on which the increased care that more fearful children receive brings increased cooperative tendencies in those children. But this proposal overlooks an equally well supported alternative on which children's anxiety - not a virtuous caring cycle - explains the cooperative tendencies of humans.

γ-Aminobutyric Acid-Ergic Development Contributes to the Enhancement of Electroencephalogram Slow-Delta Oscillations Under Volatile Anesthesia in Neonatal Rats.

Background: General anesthetics (eg, propofol and volatile anesthetics) enhance the slow-delta oscillations of the cortical electroencephalogram (EEG), which partly results from the enhancement of (γ-aminobutyric acid [GABA]) γ-aminobutyric acid-ergic (GABAergic) transmission. There is a GABAergic excitatory-inhibitory shift during postnatal development. Whether general anesthetics can enhance slow-delta oscillations in the immature brain has not yet been unequivocally determined.

Eco-anxiety: What it is and why it matters.

Researchers are increasingly trying to understand both the emotions that we experience in response to ecological crises like climate change and the ways in which these emotions might be valuable for our (psychical, psychological, and moral) wellbeing. However, much of the existing work on these issues has been hampered by conceptual and methodological difficulties. As a first step toward addressing these challenges, this review focuses on eco-anxiety.

Apprehending anxiety: an introduction to the Topical Collection on worry and wellbeing.

The aim of this collection is to show how work in the analytic philosophical tradition can shed light on the nature, value, and experience of anxiety. Contrary to widespread assumptions, anxiety is not best understood as a mental disorder, or an intrinsically debilitating state, but rather as an often valuable affective state which heightens our sensitivity to potential threats and challenges. As the contributions in this volume demonstrate, learning about anxiety can be relevant for debates, not only in the philosophy of emotion, but also in epistemology, value theory, and the philosophy of psychopathology.

Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice.

Background: Propofol total intravenous anesthesia (TIVA) is increasingly popular in pediatric anesthesia, but education on its use is variable and over-dosage adverse events are not uncommon. Recent work suggests that electroencephalogram (EEG) parameters can guide propofol dosing in the pediatric population. This education quality improvement project aimed to implement a standardized EEG TIVA training program over 12 months in a large pediatric anesthesia division.

Isoelectric Electroencephalography in Infants and Toddlers during Anesthesia for Surgery: An International Observational Study.

Background: Intraoperative isoelectric electroencephalography (EEG) has been associated with hypotension and postoperative delirium in adults. This international prospective observational study sought to determine the prevalence of isoelectric EEG in young children during anesthesia. The authors hypothesized that the prevalence of isoelectric events would be common worldwide and associated with certain anesthetic practices and intraoperative hypotension.

Timely completion of spinal fusion: A multidisciplinary quality improvement initiative to improve operating room efficiency.

Background: Failure to complete surgery within the scheduled timeframe impairs operating room efficiency leading to patient dissatisfaction and unplanned labor costs. We sought to improve timely completion (within 30 min of scheduled time) of first-case spine fusion surgery (for idiopathic scoliosis) from a baseline of 25%-80% over 12 months. We also targeted timely completion of perioperative stages within predetermined target completion times.

Functional near-infrared spectroscopy to assess pain in neonatal circumcisions.

Introduction: Pain assessment is challenging in neonates. Behavioral and physiological pain scales do not assess neocortical nociception, essential to pain encoding and central pain pathway development. Functional near-infrared spectroscopy (fNIRS) can assess neocortical activation to noxious stimuli from changes in oxy-(HbO) and total-hemoglobin concentrations (HbT).

Clinical experience of abrupt discontinuation of perampanel: a case series.

With an elimination half-life of 105 hours, perampanel (PER) allows a once-daily dosing regimen. In pivotal trials, when PER was tapered, it was therefore usually discontinued abruptly. Thus, in our hospital we have always practiced abrupt cessation.

Is the anticonvulsant activity of levetiracetam dose-dependent?

Purpose: Although levetiracetam (LEV) is globally established as a leading antiseizure medication (ASM) it is still a controversial matter whether dose increases correspond with an increased efficacy if LEV in the recommended dose range did not show satisfying efficacy. In our clinical perception we questioned the value of dose increases in such non-responders.

Methods: In this retrospective monocenter study we analyzed the data of adult people with epilepsies (PWE) with focal-onset seizures who had been treated at the department of adults of the Kork Epilepsy Center between 2009 and 2019, who had been on a stable daily LEV dose and in whom LEV was further increased due to further seizures in spite of baseline LEV in a recommended daily dose range.

An approach to using pharmacokinetics and electroencephalography for propofol anesthesia for surgery in infants.

Safe and effective techniques for propofol total intravenous anesthesia (TIVA) in infants are not well imbedded into clinical practice, resulting in practitioner unfamiliarity and potential for over- and under-dosing. In this education article, we describe our approach to TIVA dosing in infants and toddlers (birth to 36 months) which combines the use of pharmacokinetic models with EEG multi-parameter analysis. Pharmacokinetic models describe propofol and remifentanil effect site concentrations (Ce) over time in different age groups for a given dosing regimen.

Using Electroencephalography (EEG) to Guide Propofol and Sevoflurane Dosing in Pediatric Anesthesia.

Sevoflurane and propofol-based anesthetics are dosed according to vital signs, movement, and expired sevoflurane concentrations, which do not assess the anesthetic state of the brain and, therefore, risk underdose and overdose. Electroencephalography (EEG) measures cortical brain activity and can assess hypnotic depth, a key component of the anesthetic state. Application of sevoflurane and propofol pharmacology along with EEG parameters can more precisely guide dosing to achieve the desired anesthetic state for an individual pediatric patient.

Is brivaracetam-induced elevation of carbamazepine-epoxide levels common and clinically relevant? - A case series.

Brivaracetam (BRV) was recently introduced for the treatment of patients with focal epilepsy. BRV undergoes relatively few interactions, but one of them leads to the elevation of carbamazepine (CBZ)-10,11-CBZ-epoxide (CBZ-E) if BRV is co-administered with CBZ. This interaction has been considered to be clinically negligible.

What sentimentalists should say about emotion.

Recent work by emotion researchers indicates that emotions have a multilevel structure. Sophisticated sentimentalists should take note of this work - for it better enables them to defend a substantive role for emotion in moral cognition. Contra May's rationalist criticisms, emotions are not only able to carry morally relevant information, but can also substantially influence moral judgment and reasoning.

Prevalence of Isoelectric Electroencephalography Events in Infants and Young Children Undergoing General Anesthesia.

Background: In infants and young children, anesthetic dosing is based on population pharmacokinetics and patient hemodynamics not on patient-specific brain activity. Electroencephalography (EEG) provides insight into brain activity during anesthesia. The primary goal of this prospective observational pilot study was to assess the prevalence of isoelectric EEG events-a sign of deep anesthesia-in infants and young children undergoing general anesthesia using sevoflurane or propofol infusion for maintenance.