Anesthesia Patient Safety Podcast

#286 Pediatric Anesthesia Safety: Past Gains, Next Frontiers

• Anesthesia Patient Safety Foundation • Episode 286

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Safety for children under anesthesia shouldn’t depend on luck or location. We walk through 100+ years of progress in pediatric anesthesia and focus on the next wave of innovations that can make first attempts safer, dosing smarter, and systems more reliable—especially for neonates and infants who face the highest risk.

We start with the historical milestones that changed outcomes: pulse oximetry, capnography, standardized monitoring, and the rise of pediatric training and ICUs. Then we examine where progress must accelerate. Video laryngoscopy is improving first-pass success and reducing desaturation by giving teams a brighter, shared view of the airway. Ultrasound enhanced by AI promises needle guidance, better vascular access, and more consistent regional anesthesia. Gastric ultrasound could reshape fasting practices, reducing hypotension, nausea, and anxiety while safeguarding against aspiration. Alongside these tools, processed EEG helps tailor volatile agents and propofol to the developing brain, pushing practice from population averages to precision dosing.

We also look ahead to artificial intelligence as a connective layer across perioperative care. Think risk stratification in the EHR, early-warning analytics for intraoperative instability, and smarter OR management that reduces cancellations and costs. With expert insights from pediatric anesthesiologist, Dr. Elizabeth Malinzak, we name the real barriers—training, cost, bias, regulation—and stake a claim for proactive safety science over reactive fixes. The goal is equitable, high-quality anesthesia care for every child, in every setting.

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For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/286-pediatric-anesthesia-safety-past-gains-next-frontiers/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_01:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are so excited because it is finally time to discuss the amazing articles from the October 2025 APSF newsletter. Let's kick off this series by talking about keeping our youngest patients safe during anesthesia care. Over the past 40 years, pediatric anesthesia safety has improved with advances in monitoring, pharmacology, airway management, and safety culture. There is still more work to be done when it comes to perioperative risk for neonates and infants, medication safety, neurodevelopmental concerns, and global disparities. Going forward, we hope to see a focus on simulation, data-driven practice, and equitable worldwide access to safe pediatric anesthesia care. As you can see, we have a lot to talk about today. Before we dive further into the episode, we'd like to recognize BD, a major corporate supporter of APSF. BD has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, BD. We wouldn't be able to do all that we do without you. Our featured article today is Pediatric Anesthesia Safety, Yesterday, Today, and Tomorrow by Elizabeth Mallenzack and colleagues. To follow along with us, head over to apf.org and click on the newsletter heading. The first one down is the current issue. From there, scroll down to our featured article today. And I will include a link in the show notes as well. To help kick off the show today, we are going to hear from one of the authors. Here she is now.

SPEAKER_00:

Hi, my name is Elizabeth Mallenzack, and I am a pediatric anesthesiologist at Duke University Hospital in Durham, North Carolina.

SPEAKER_01:

I asked Elizabeth why she feels so passionate about this area of anesthesia. Let's take a listen to what she had to say.

SPEAKER_00:

I'm really interested in the history and the future of safety in pediatric anesthesia. First of all, because I find history incredibly interesting to see how far we have come in such a short period of time of making things better for our patients. And as I see new innovations and new technology come to play so quickly today, I'm really interested to see how that will improve our care of patients for the future.

SPEAKER_01:

Now it's time to get into the article. The authors highlight the following key points when it comes to safe pediatric anesthesia care. Mortality and major complications in pediatric anesthesia have declined with the use of pulsoximetry, capnography, and standardized monitoring. Airway management and drug safety remain central safety concerns, especially in neonates and infants. Research continues on anesthetic neurotoxicity and long-term neurodevelopmental outcomes. Global disparities in pediatric anesthesia safety require international collaboration and resource development. And future directions emphasize big data, precision medicine, and equity in care delivery. Let's take a closer look at the history of pediatric anesthesia. The focus on safety in pediatric anesthesia started back in the 1840s, shortly after the introduction of anesthesia for dental and surgical procedures following the death of a 15-year-old girl during chloroform anesthesia. John Snow was an anesthesiologist, epidemiologist, and author of the earliest anesthesia textbooks, and he quickly identified the specialized field of pediatric anesthesia. We have known for a long time that children are not just small adults, and instead, the vast differences in age, weight, anatomy, and psychosocial development are important considerations for providing safe anesthesia care. We have come a long way since then. Check out Table 1 in the article for a review of the historical safety innovations in pediatric anesthesiology over the 30-year time periods starting from 1860. I will include this table in the show notes as well. From 1860 to 1890, the innovations include ether and chloroform anesthesia with monitoring of pulse rate and respiratory rate. From 1890 to 1920, we see the introduction of nitrous oxide, the vaporizer, and thiopental, as well as the hypodermic needle and oral airway. This is also when the mask, circuit, and anesthesia machines came on the scene, and when we see anesthesia professionals separate from surgeons and dentists. Did you know that the first pediatric anesthesia textbook, Anesthesia in Children, was published in 1923? The next 30-year period brings us many additional components of modern pediatric anesthesia care, including laryngoscopes and endotracheal tubes, the pediatric circuit and ventilator, monitoring with ECG and blood pressure, IV fluids, and the warming blanket. This is also when we see neuromuscular blockade with Curare. The American Society of Anesthesiologists is formed during this time as well as anesthesia residencies and safety conferences. Between 1847 and 1956, pediatric, perioperative, and anesthesia-related mortality decreases from 49 to 29 cases per 100,000. Next, from 1950 to 1980, the innovations include halothane and ketamine, as well as determination of the minimum alveolar concentration, or MAC, which improved the delivery of volatile anesthetics. Blood gas analysis was first developed as well. This is also when we see the first pediatric fellowships, as well as PICU and NICUs in hospitals to allow for improved postoperative monitoring and specialized care for neonates and infants. There was a significant decrease in pediatric anesthesia-related mortality down to eight per 100,000 over this time period. From 1980 until 2010, our modern anesthetics enter practice with propofol and sevofluorine, as well as additional monitoring with N-tital CO2, pulse oximetry, and N-tital Volatile Anesthetic Concentrations. The laryngeal mask airway is developed to help with difficult airway management, and the first electronic health records are used. ASA Practice Standards, the Society for Pediatric Anesthesia, or SPA, and the Anesthesia Patient Safety Foundation, yay! were created and helped to provide education for pediatric anesthesia professionals to adopt safe practices. Pediatric perioperative mortality decreased to 24 per 100,000 cases, and pediatric anesthesia-related mortality declined once again down to four per 100,000 cases. Our current 30-year period involves the use of dexmenatominine, video laryngoscopes, and processed EEG monitoring, as well as the creation of the special American Board of Anesthesiology certification and pediatrics. The focus is on education and organization rather than just technological advancements, although we are just starting to see the use of image analysis ultrasound and the use of AI during pediatric anesthesia care. There has been a big effort to adopt safety science for hospitals and professional organizations, including the Safety One framework, which includes education, creation of pediatric standards and safety departments, and implementation of electronic health records. Using electronic health records has then allowed for the development of databases, analytics, metrics, lookup tables, checklists, and critical notifications as tools to support perioperative patient safety. Pediatric anesthesia safety innovations include SPA's Wake Up Safe organization that offers tools for safety analytics and quality improvement, as well as SPA's quality standards for pediatric perioperative care. Once again, these efforts are rewarded with decreases in pediatric perioperative mortality down to 11 per 100,000 cases, and pediatric anesthesia-related mortality down to 0.5 per 100,000 cases, which is once again a two to five-fold less than the previous period. Now that we have reviewed the history, let's take a look at where we are going. Over the next 10 years, the workload for pediatric anesthesia professionals will continue to grow due to higher acuity patients and more complicated procedures. At the same time, there are concerns about a shortage of trained anesthesia professionals since half of current pediatric anesthesiology fellowships remain unfilled. We will need further innovations to help maintain and continue to improve pediatric patient safety, especially when it comes to nonfatal adverse events such as airway and cardiopulmonary events, which occur more often in neonates and infants, ASA 3 to 4 patients, and those undergoing major surgery. Now it's time to talk about innovations. And first up is the video laryngoscope. This is an excellent tool in our airway toolbox to help improve the reliability of first-attempt intubation success in neonates, infants, and children with difficult airways with the brighter and larger view of the larynx, and a video screen that allows other clinicians to assess the anatomy and verify intubation. In neonates, there is limited space to place the laryngoscope blade, view the anatomy, and insert the endotracheal tube before desaturation occurs. And video laryngoscopy has been shown to increase successful first-attempt intubation rates as well as decrease desaturation and cardiovascular events. There is varied adoption of the use of video laryngoscope in pediatric anesthesiology, from standard practice in some departments to clinician-dependent or even unavailable in other departments. Barriers to consistent use of video laryngoscopy include change in practice and training from direct laryngoscopy, as well as the cost and sustainability of this equipment. Next up, have you heard of image analysis ultrasound? Computer-generated image analysis ultrasound is currently used in radiology, and ultrasound machines can provide image analysis with artificial intelligence to help identify structures and needle placement with real-time feedback for the clinician and trainee. Anesthesia professionals can use ultrasound to help with diagnosis of causes of hypotension, low cardiac output, and poor ventilation, as well as for vascular access and regional procedures. These evaluations and procedures are often difficult in neonates in infants due to the small size, variable anatomy, infrequent use of the technology, and challenges with scalability of AI assistants. Barriers for adoption of image analysis ultrasound include lack of education and exposure to the technology, the high cost, and the large size of the machines in small operating rooms. Our next area for innovation involves gastric ultrasound and fasting. The 2017 Apricot study was a large, prospective, multi-center cohort study of fasted and unfasted children undergoing elective and urgent surgery in 33 European countries, which reported an incidence of aspiration of 9.3 in 10,000 cases and no severe complications. In our current practice, preoperative fasting duration for children is often much longer than the established guidelines, leading to increased irritability, nausea, vomiting, dehydration, hypotension, and anxiety. Many European pediatric anesthesiology societies support a one-hour fasting interval for clear liquids, while the ASA maintains a two-hour recommendation. Gastric ultrasound, especially with image analysis, may be a useful tool to assess preoperative gastric volume and aspiration risk in children. Going forward, gastric ultrasound could provide additional data to help with future guidelines and even the potential for individualized fasting protocols based on real-time assessment. Are you using a process EEG monitor? This is another important tool that can improve the precision of anesthetic dosing for children, infants, and neonates and prevent inadvertent overdose. This technology for pediatric anesthesiology is still in the early adoption phase due to the lack of devices in many departments, as well as the need for more research, education, and clinical training with the technology. But the evidence to support its use is growing. The technology is also improving, and new EEG monitors have revealed that current dosing practices recommend more sevofluorine and propofol than necessary in all patients, and unhealthy patients often require a lower dose for the same EEG features as healthy patients, and inadvertent overdosing is associated with worse outcomes. The authors state that EEG-guided anesthesia has the potential to transform pediatric anesthesiology practice from population-based dosing to patient precision dosing for the brain in all patients. This is an exciting space to watch going forward. And speaking of exciting, we cannot talk about the future without discussing what role artificial intelligence may play in the field of pediatric anesthesiology. Right now we are at the pre-adoption phase. AI is something that could be added into processed EEG and video laryngoscopy, just like image analysis and ultrasound. There is also a tremendous opportunity for AI-integrated electronic health records to help with pre-operative risk stratification. AI-assisted monitoring to provide interoperative alerts about the potential for adverse events, and guide ventilation settings and medication dosing based on real-time vital signs, weight, and height. Pediatric operating room management may be facilitated by AI to assist with workflows and resource allocation to help with same-day add-on cases, and the increasing number of non-operating room cases, ultimately leading to reduced cancellations, optimized efficiency, and reduction of cost. Barriers to AI technology include ethical issues when using patient data, algorithms subject to bias and response latency, the high cost, lack of regulations, liability, implementation requirements, and the broad contextual factors considered in clinical decision making by pediatric anesthesia professionals that may be missed by AI models. As we have seen, pediatric anesthesiology has come a long way over the past 100 years with significantly improved anesthesia patient safety. Going forward, there will be significant challenges with workforce shortages and increased patient and procedure complexity. The authors advocate that to meet these challenges, pediatric anesthesiology must shift towards proactive system design, resilience, and real-time adaptation of tools to enhance precision and efficiency. To do this, we need to overcome the barriers that we talked about today, including education, cost, scalability, and trust. The authors leave us with this call to action. By investing in tools within safety science frameworks, pediatric anesthesia professionals can continue to lead in advancing safe, equitable, and high-quality care for the most vulnerable and complex patients. We hope that you will help to answer this call to action. Before we wrap up for today, we are going to hear from Elizabeth again. I also asked her what she envisions for the future when it comes to pediatric anesthesia care. Here is her response.

SPEAKER_00:

I really hope that as we move into the future, we start taking more of a proactive approach to our patient safety rather than reactive approach. I feel right now that most of our discussions around safety or quality improvement are in regards to when a bad event happens. And I'd really like for us to focus on preventing things from happening to our smallest patients in the future.

SPEAKER_01:

Thank you so much to Elizabeth for contributing to our show today and for your work on pediatric patient safety. We are looking forward to a future where we are preventing adverse events from ever occurring when pediatric patients undergo surgery and anesthesia.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apf.org for detailed information and check out the show notes for links to all the topics we discussed today. Before you go, we hope that you will take a moment to like, review, and share the Anesthesia Patient Safety podcast with just one colleague, trainee, or team member, quick before the end of the year. Our listeners are increasing every year, and we are already looking forward to bringing you the best in perioperative and anesthesia patient safety in 2026 and beyond. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.