Postoperative pulmonary complications (PPCs) are common, costly, and increase patient mortality. Changes to the respiratory system occur immediately on induction of general anaesthesia: respiratory drive and muscle function are altered, lung volumes reduced, and atelectasis develops in > 75% of patients receiving a neuromuscular blocking drug. The respiratory system may take 6 weeks to return to its preoperative state after general anaesthesia for major surgery. Risk factors for PPC development are numerous, and clinicians should be aware of non-modifiable and modifiable factors in order to recognize those at risk and optimize their care. Many validated risk prediction models are described. These have been useful for improving our understanding of PPC development, but there remains inadequate consensus for them to be useful clinically. Preventative measures include preoperative optimization of co-morbidities, smoking cessation, and correction of anaemia, in addition to intraoperative protective ventilation strategies and appropriate management of neuromuscular blocking drugs. Protective ventilation includes low tidal volumes, which must be calculated according to the patient's ideal body weight. Further evidence for the most beneficial level of PEEP is required, and on-going randomized trials will hopefully provide more information. When PEEP is used, it may be useful to precede this with a recruitment manoeuvre if atelectasis is suspected. For high-risk patients, surgical time should be minimized. After surgery, nasogastric tubes should be avoided and analgesia optimized. A postoperative mobilization, chest physiotherapy, and oral hygiene bundle reduces PPCs.

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n¼5609) born at mean (standard deviation [SD]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO 2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]¼1.16; 95% confidence interval [CI], 1.04e1.28

Background: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. Methods: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. Results: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1e6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO 2 <90% for 60 s) was reported in 40%. No associated risk factors could be identified among comorbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. Conclusions:The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. Clinical trial registration: NCT02350348.

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Background: Postoperative sore throat is common after general anesthesia. The incidence in pediatric anesthesia is variable, and the etiology unclear. Establishing risk factors would enable prevention and could improve quality of care. Aims:We performed a prospective single-center cohort study aiming to establish the incidence of postoperative sore throat in children undergoing GA with an endotracheal tube or laryngeal mask airway. Secondary aims were to identify independent risk factors for sore throat and the incidence of other postoperative complications including stridor, laryngospasm, nausea and vomiting, and delayed oral intake. Methods: Between November 2017 and April 2018, perioperative data were collected from children aged 5-16 years undergoing general, plastic, urology, renal, and orthopedic surgery. Patients completed a postoperative questionnaire within 24 hours of surgery. Results:We screened 334 children for inclusion at a tertiary pediatric hospital in the United Kingdom. One hundred and ninety-seven patients were included in the final analysis. The frequency of postoperative sore throat was 36.5%. Stridor occurred in 1.5%, laryngospasm 1.0%, postoperative nausea 59.4%, vomiting in recovery 4.6%, and delayed oral intake due to postoperative sore throat 30%. Nausea, vomiting, thirst, and pain were associated with a sore throat. Univariate analysis showed anesthesia longer than 2 hours, and use of an endotracheal tube was statistically associated with higher risk of sore throat. Over 50% of children with an endotracheal tube cuff pressure <20 cmH 2 O had a postoperative sore throat. Conclusion:Postoperative sore throat is common in children. Endotracheal intubation is associated with a greater incidence than laryngeal mask airway use. A high rate of postoperative sore throat in children with endotracheal tube cuff pressures within the recommended range suggests multifactorial etiology. To confirm validity of the identified risk factors, we would recommend a larger prospective multi-center study. K E Y W O R D Schild, incidence, intubation, laryngeal masks, pharyngitis, postoperative period