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The percentage of patients with at least 1 unnecessary test is a suitable end point for monitoring providers' ordering. The incidence can be high despite efforts at improvement, but may be reduced if anesthesiologists rather than surgeons order presurgical tests and consults. However, anesthesia groups should be cognizant of potential heterogeneity among them based on time since training.

Highlights A patient with Myasthenia Gravis (MG) on immunosuppressive therapy with underlying respiratory compromise may be more susceptible to infection with COVID-19 or severe manifestations of the virus. It is theorized that patients with MG may be more vulnerable to bacterial and viral infections, due to respiratory muscle weakness and use of immunosuppressive medications. It is critical for practitioners to be prepared for severe respiratory compromise in patients with MG and concomitant COVID-19 superinfection. In light of the COVID-19 pandemic, MG patients should be encouraged to continue their current treatment regimens, but engage in extra vigilant social distancing.

An alarming and distressing delayed inflammatory response to Coronavirus Disease 2019 (COVID-19) has emerged in children and adolescents, a population previously thought to have been largely spared by this global pandemic. In April 2020, clinicians in the United Kingdom identified eight cases of previously healthy children testing positive for current or recent infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) presenting with Kawasaki disease-like features. From April 16 to May 4, 2020, New York City reported that 15 patients aged 2-15 years were hospitalized with a similar multisystem inflammatory syndrome, many requiring intensive care unit (ICU) admission. This syndrome is referred to either as pediatric inflammatory multisystem syndrome, or multisystem inflammatory syndrome in children (MIS-C). We present the case of an eight-year-old with MIS-C who developed carotid artery dissection following venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannulation, followed by a subsequent hemorrhagic stroke in the basal ganglia.

Background: Antifibrinolytics such as tranexamic acid and epsilon-aminocaproic acid are effective at reducing blood loss and transfusion in pediatric patients having craniofacial surgery. The Pediatric Craniofacial Collaborative Group has previously reported low rates of seizures and thromboembolic events (equal to no antifibrinolytic given) in open craniofacial surgery. Aims: To query the Pediatric Craniofacial Collaborative Group database to provide an updated antifibrinolytic safety profile in children given that antifibrinolytics have become recommended standard of care in this surgical population. Additionally, we include the population of younger infants having minimally invasive procedures. Methods: Patients in the Pediatric Craniofacial Collaborative Group registry between June 2012 and March 2021 having open craniofacial surgery (fronto-orbital advancement, mid and posterior vault, total cranial vault remodeling, intracranial LeFort III monobloc), endoscopic cranial suture release, and spring mediated cranioplasty were included. The primary outcome is the rate of postoperative complications possibly attributable to antifibrinolytic use (seizures, seizure-like activity, and thromboembolic events) in infants and children undergoing craniosynostosis surgery who did or did not receive antifibrinolytics.Results: Forty-five institutions reporting 6583 patients were included. The overall seizure rate was 0.24% (95% CI: 0.14, 0.39%), with 0.20% in the no Antifibrinolytic group and 0.26% in the combined Antifibrinolytic group, with no statistically reported difference. Comparing seizure rates between tranexamic acid (0.22%) and epsilon-aminocaproic acid (0.44%), there was no statistically significant difference (odds ratio = 2.0; 95% CI: 0.6, 6.7; p = .257). Seizure rate was higher in patients greater than 6 months (0.30% vs. 0.18%; p = .327), patients undergoing open procedures (0.30% vs. 0.06%; p = .141), and syndromic patients (0.70% vs. 0.19%; p = .009).

Background Peters anomaly is a rare, congenital eye malformation characterized by an opaque cornea and blurred vision. Central corneal opacification can lead to delayed progression of visual development caused by defects in Descemet membrane and the posterior stroma. These children require several anesthetics for multiple eye examinations under anesthesia and corneal transplantation. Aims We sought to review the anesthetic management of patients with Peters anomaly for ophthalmologic procedures at Westchester Medical Center, a major referral center for Peters anomaly. Methods A retrospective chart review was completed which included pediatric patients who underwent ophthalmologic procedures related to Peters anomaly from 2013‐2018. Results The charts of 35 patients with Peters anomaly were reviewed: 14 patients with Peters anomaly Type I, 10 patients with Peters anomaly Type II, and 11 patients with Peters plus syndrome. Thirty patients required three procedures on average, two examinations under anesthesia pre‐ and post‐transplant, and anesthesia for the corneal transplant itself. The youngest patient encountered for examination under anesthesia was 39‐week postconceptual age. Anesthetic time for examination under anesthesia averaged 31 minutes using a laryngeal mask airway while corneal transplant averaged 104 minutes utilizing endotracheal intubation. Postanesthesia care unit stay averaged 51 minutes following examination under anesthesia and 65 minutes after corneal transplant. All examinations under anesthesia were successfully completed without adverse events with the use of a laryngeal mask airway. This case series includes two patients with Goldenhar syndrome and Al‐Gazali syndrome accompanying Peters anomaly. Conclusion Although limited by its retrospective nature, this case series describes the cardiac and systemic implications of patients undergoing anesthesia with Peters anomaly. Our experience indicates that general anesthesia and airway manipulation are tolerated with minor postoperative concerns in these infants. Pediatric patients with Peters anomaly require multiple anesthetics for repeated ophthalmologic interventions. The laryngeal mask airway can be routinely utilized in infants less than 3 months of age for an eye examination under anesthesia with no airway complications noted. Perioperative providers should be aware of the multisystemic implications in patients with Peters plus syndrome.

Kniest dysplasia, or metatropic dysplasia type II, is a rare chondrodysplasia caused by abnormal type II collagen. Clinically, it is characterized by dwarfism, deafness, skeletal derangements, and ocular abnormalities. Mitochondrial diseases produce a spectrum of abnormalities in affected individuals and predominantly impact organs of high energy utilization, including the brain, skeletal muscles, kidneys, and liver. We present the case of a 6-year-old boy with both Kniest dysplasia and underlying mitochondrial disease for examination under anesthesia before cataract surgery. Successful anesthetic management of a patient with Kniest dysplasia and a mitochondrial myopathy is discussed.

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