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We present a case in which intramuscular rocuronium was used successfully to treat laryngospasm in a pediatric patient. An 11-month-old infant weighing 9.7 kg was scheduled for an elective laparoscopic inguinal hernia repair surgery. Anesthesia was induced with oxygen, nitrous oxide, and sevoflurane. After loss of consciousness, mask ventilation became impossible, and laryngospasm was suspected. Intravenous access was attempted without success; as there was no immediate access to succinylcholine, rocuronium 10 mg (1.0 mg/kg) was injected intramuscularly into the vastus lateralis muscle. We were able to mask-ventilate the patient within one minute of intramuscular rocuronium, followed by successful endotracheal intubation with a video laryngoscope. The duration of hypoxia (saturation of peripheral oxygen (SpO2) < 90%) was approximately two minutes, and the patient\'s lowest oxygen saturation during induction was 76%. At the end of the surgery, the patient was uneventfully extubated. We conclude that intramuscular rocuronium may provide an alternative treatment for laryngospasm in pediatric patients with no intravenous access and no availability of succinylcholine.

Controlling preoperative anxiety is necessary in pediatric patients to avoid adverse effects such as emergence delirium, behavioral problems, post-traumatic stress disorder, anxiety prior to future procedures, and increased analgesic doses in the recovery room. Some patients, especially ones with behavioral issues, have a difficult time arriving at the hospital. Medications given at home can be helpful. We describe a case series of six patients who received pre-admission oral clonidine prior to arrival to the hospital. The patients were all able to enter the hospital without difficulty and the families reported less anxiety and more cooperation subjectively compared with previous experiences. Transient intraoperative hypotension was a side effect of oral clonidine, with no long-term sequelae.

Rett Syndrome (RTT) is a rare, severe, and progressive developmental disorder with intellectual disability. Anesthesia in RTT patients presents a range of challenges. We report a child with RTT who received dental treatment under muscle relaxant-free general anesthesia in our ambulatory center.
A 15-year-old girl with RTT was admitted to our dental clinic with multiple dental caries and residual roots. Dental treatment was scheduled under ambulatory general anesthesia. After anesthesia induction, a nasal tube was initiated under the guidance of a fiberoptic bronchoscope. Multimodal analgesia, body temperature monitoring, and postoperative nausea and vomiting prevention were applied. No muscle relaxants were used throughout the process. The endotracheal tube was successfully removed after the operation and the patient was discharged home the same day.
An individualized anesthesia strategy enabled a quick and safe recovery for this RTT patient after dental treatment under muscle relaxant-free general anesthesia.

This report focuses on the clinical course and treatment of an infant male who had a progressively enlarging tongue mass initially thought to be an infantile hemangioma but was later found to be an infantile fibrosarcoma. Treatment included surgical excision with anticipated difficult mask ventilation with active rhino/enterovirus infection bronchiolitis and recent croup. Complete surgical excision is the mainstay of treatment, and the patient did have negative margins after complete surgical re-excision. The patient has surveillance MRI scans and remains without fibrosarcoma recurrence. This case report highlights complex pediatric airway management and the need for vigilance in healthcare when common presentations, such as infantile hemangioma, also present with a concurrent rare disease at a different anatomic location, such as infantile fibrosarcoma in this case.

Bone marrow harvesting is a means to obtain stem cells to treat certain hematologic conditions in related or unrelated individuals. The most cited complication after bone marrow harvesting is surgical site pain. We developed a protocol incorporating regional anesthesia to improve pain control and reduce opioid use. A retrospective chart review was performed on three pediatric patients who underwent bone marrow harvesting for a sibling recipient and were managed via a standardized regional pain protocol. Each patient was treated with bilateral quadratus lumborum blocks in the operating room, prior to incision. Anesthesia records were reviewed for opioid administration intraoperatively and postoperatively. Two of three patients underwent successful QL blocks as evidenced by pain scores of 0/10 and lack of opioid administration in the post-anesthesia care unit. One patient was found to have a failed block and exhibited pain in the immediate and post-discharge time frame. Following this outpatient procedure, all patients were discharged home to the care of their parents, and no patients required admission due to pain. By utilizing the framework of a successful regional anesthesia model adapted from our adult bone marrow donor patients, we were able to employ a minimal opioid anesthetic and reunite patients with their families efficiently. We continue to use quadratus lumborum blocks in our pediatric patients to facilitate perioperative analgesia.

Children with trisomy 18 have abnormal airway anatomy, making their airway management challenging. Only a few papers have comprehensively described and discussed the use of supraglottic airway devices in patients with trisomy 18. We present a case of a 20-month-old boy with trisomy 18 who was scheduled for open repair of the right inguinal hernia. He had micrognathia, a short neck, and an atrial septal defect but was in a clinically stable condition. A supraglottic airway device was inserted under general anesthesia. The patient\'s respiration was maintained by pressure support ventilation with spontaneous breathing. A right ilioinguinal-iliohypogastric nerve block was performed for perioperative analgesia. The surgery ended without complications. After removing the supraglottic airway device and ensuring proper respiratory parameters, the patient was transferred to the post-anesthesia care unit. In our case, supraglottic airway devices could be effectively used as a primary airway for inguinal hernia repair. The concomitant ilioinguinal-iliohypogastric nerve block was helpful for anesthetic management with spontaneous breathing maintained using pressure support ventilation. A supraglottic airway device may be a potential alternative as a primary airway for superficial surgery in pediatric patients with trisomy 18. For pediatric patients with difficult airways, a second-generation supraglottic airway device with the insertion of a gastric tube to prevent gastric insufflation combining pressure support ventilation and positive end-expiratory pressure may be a beneficial choice for the maintenance of spontaneous breathing.

BACKGROUND: Increasing procedures in day-case surgery can mitigate the costs of health service, without reducing safety and quality standards. The Ospedale Pediatrico Bambino Gesù has adopted an educational program for healthcare personnel and patients\' families to increase the number of day-case surgery procedures performed without reducing the level of safety. The unplanned admission rate after day-case surgery can be a quality benchmark for pediatric day-case surgery, and in literature, there are no Italian data.
METHODS: We made a retrospective analysis of the hospital database and focused on children requiring unplanned admission to the central venue of the hospital for the night. The audit covered the period from September 2012 to April 2018.
RESULTS: We performed general anesthesia for 8826 procedures (urology 33.60%, plastic surgery 30.87%, general surgery 17.44%, dermatology 11.66%, dentistry 3.16%, orthopedics 1.64%, digestive endoscopy 1.63%). Unplanned admission for anesthetic reasons resulted in two cases: one case of syncope and one case of vomit (0.023% rate). No one major complication.
CONCLUSIONS: Good quality of patient selection, the safety of the structure, family education, and an efficient organizational model combined with an educational program for anesthesiologists can improve the safety of anesthesia for day-case surgery.

Multisystem inflammatory syndrome in children (MIS-C) is an immune response inciting multiorgan dysfunction and a shock-like state which is typically seen in children 2 to 6 weeks after either a coronavirus disease-19 infection or exposure. When such a child comes for any surgery, perioperative anesthetic management demands multidisciplinary involvement and individualized case-based decision-making. Due to the novelty of the condition, there are limited data on anesthetic implications in these patients. Anesthetic management in the affected children is dynamic depending on the organ systems involved and the progression of the disease state. Though the long-term effects of the syndrome are largely unknown, we hope that awareness of the MIS-C-associated complications may help anesthesiologists involved in childcare. Herein, we put forward challenges and clinical dilemmas we faced during the anesthetic management of three children with MIS-C presenting for emergency and elective surgery.

BACKGROUND: Klippel-Feil syndrome (KFS) occurs in 1/40,000 individuals and is characterized by cervical fusion. Thirty percent of patients with KFS present with Sprengel deformity, leading to orthopedic problems and limited shoulder abduction. No reports exist regarding anesthetic procedures for pediatric scapular osteotomies.
METHODS: We report a case of a 4-year-and-7-month-old boy (95.6 cm, 14.7 kg) who underwent left scapular osteotomy. At the age of 8 months, he also underwent a right lower lobectomy due to a congenital pulmonary airway malformation. We decided to use a combination of suprascapular nerve block (SSNB), erector spinae plane block (ESPB), and general anesthesia. He received regular acetaminophen administration and fentanyl 5-10 μg/hour intravenously until 20 h postoperatively and remained on ≤ 2/10 in the Wong-Baker Face Scale (0: no hurt; 10: hurts worst).
CONCLUSIONS: The combination of SSNB and ESPB could be an option for perioperative analgesia for scapular osteotomies.