Global perspectives on pediatric anesthesia

For 20 years before the COVID-19 pandemic, the world became increasingly connected and collaborative, thanks to the internet, social media, informatics, multinational businesses, academia, and political leadership. In this tide of goodwill at a global level, pediatric anesthesia built many multinational collaborations in clinical care, research, education, and quality/safety. The journal facilitated these multinational networks by convening leadership meetings of pediatric anesthesia societies, and by diversifying the board to include members from countries worldwide. Furthermore, we felt optimistic about our future as a sub-specialty and for improving perioperative and anesthesia care in children across the world. While there are formidable challenges to health equity, safety, and improved perioperative outcomes, we believed that as a connected, collaborative pediatric anesthesia world community, we could advance this mission. In this mindset, the idea for a themed issue on global pediatric anesthesia was born in 2020 (pre-COVID), which the Board of Pediatric Anesthesia enthusiastically supported. We had three goals in mind for the themed issue. First, we wanted to collect a description of pediatric anesthesia clinical delivery and education systems in many countries, which had never been done before.1-8 Second, we wanted to highlight the on-going multinational research, education, and quality/safety collaborations, along with the operational challenges of these networks.9, 10 The special issue therefore delves into three main themes: Pediatric Anesthesia Training, Patient Safety and Quality, and Pediatric Anesthesia Research Initiatives. Third, we wanted the themed issue to encourage more multinational collaboration. We wanted to invite as many authors from as many countries representing all regions of the world as possible, to write manuscripts together (co-authorship). This proved to be easier said than done. The journal has criteria for length of manuscript and the number in an issue. The sky was not the limit. To this end, we used geography (e.g., continents) for grouping countries. We enlisted the geographically diverse, well connected pediatric anesthesia board to recommend the authors in these groupings. Most manuscripts contain several countries separated by sections. Unfortunately, not all countries could be included in the themed issue. Nevertheless, the themed issue describes the clinical pediatric delivery and education systems, along with the challenges and potential solutions of at least 40 countries. The articles reflect the observations and experiences of the authors as educational reviews, not necessarily as data-driven research papers. Pediatric anesthesia is a vital component of global health, as millions of children require safe and effective anesthesia and pain management for surgery, trauma, and chronic conditions. In this issue, several challenges are enumerated in the provision and quality of pediatric anesthesia care, in low- and middle-income countries (LMICs) as well as high-income countries (HIC).2, 3, 5, 11 For the LMIC, the limitations included too few anesthesiologists, insufficient facilities, little pediatric anesthesia education, and shortages of supplies and equipment. Perhaps less known are the shortages of pediatric anesthesiologists, supplies, and drugs since COVID in the HIC. A common theme around the world is too few pediatric anesthesiologists and insufficient pediatric training during anesthesia residency for general anesthesiologists to care for the number of children needing surgery, imaging, and interventional procedures, particularly infants and medically complex children.12 Perhaps our specialty (anesthesiology) is not collectively advocating strongly enough to the government for more funding of training positions? This anesthesia shortage is afflicting certain populations of children more than others. In countries of large land mass, children in rural areas do not receive timely care due to anesthesia shortages and experience worse perioperative outcomes than those in urban centers in both LMIC and HIC. For a variety of reasons, children of indigenous origin, in low-income families, and immigrant populations in HIC experience barriers to timely access of care due to anesthesia shortages and have worse perioperative outcomes.13 Canada offers a potential solution in rural areas.14 The issue highlights the disparities in pediatric anesthesia training across different regions. It underscores the need for standardized training protocols and the sharing of best practices. By learning from diverse healthcare systems, there is an opportunity to develop a more cohesive, global approach to training that ensures all practitioners, regardless of location, have the skills, and knowledge to provide safe and effective anesthesia care for children. Patient Safety and Quality is also a common theme, reflecting the global commitment to making pediatric anesthesia as safe as possible. Articles discuss innovations in safety protocols, the use of technology to improve care, and the importance of a culture that prioritizes patient safety. This theme resonates with the universal objective of healthcare—to do no harm, especially to our youngest and most vulnerable patients. The issue also sheds light on the various pediatric anesthesia research initiatives underway around the world. These initiatives are crucial in advancing our understanding of pediatric anesthesia, developing new techniques, and improving outcomes while flattening existing hierarchies.15 Collaboration in research and clinical discussion as demonstrated by multinational pediatric anesthesia research networks and registries is a positive step towards a future where pediatric anesthesia is not only safer but also more effective and accessible to all children, regardless of their geographic location.16-20 Since the idea for the themed issue was conceived, the world has changed geopolitically post-COVID. There are wars in the Middle East, Eastern Europe, Africa, and armed conflicts in other regions. Wars and conflicts have led to humanitarian crises, disrupting healthcare systems and making access to quality medical care, including anesthesia services for children, unavailable or dangerously poor. These conflicts resonate globally, affecting healthcare supply chains, healthcare resources (funding), and international (e.g., NGO) aid.8 There is also tension between democracies and autocracies, waging cyber-attacks and misinformation campaigns. Distrust has promoted national security and military defense over goodwill and collaboration in business well as healthcare. The themed issue points out that our research, education, and quality/safety networks are being hindered by barriers to data sharing due to national security concerns, impairing the functionality of the networks to work and learn together. Since COVID, more forces seem to separate us than unite us. In this adverse geopolitical situation, how can we advance the field of pediatric anesthesia and improve the quality and safety of perioperative care for children globally? We must take the long view, stick with our mission and not give up, and advocate politically for our cause. We must stay united in our fight against child illnesses that require anesthesia, critical care, and pain management. These illnesses will exist for longer than the politicians who wage divisions in our world. History proves politics is fickle- the world is in a disruptive phase. We must stay focused on our mission: advance our specialty through research, education, and quality/safety sciences. As long as we continue to train pediatric anesthesiologists to take up the fight against child illnesses and advance our mission, we will outlast this disruptive phase. Finally, we must advocate for the cause of pediatric anesthesia, critical care, and pain management. Children cannot get surgery without anesthesia! The WHO reports that as many children die from lack of surgical care than infectious diseases. By focusing on the universal goal of patient safety and quality care for the most vulnerable—our children—pediatric anesthesiologists worldwide are demonstrating that collaboration can prevail over division.8, 12 The journal can continue to facilitate collaboration of the pediatric anesthesia societies in the world to better advocate in their countries. We are proud to present this special issue of the Journal of Pediatric Anesthesia, which showcases the diversity and richness of pediatric anesthesia practice, research, and education across different settings and contexts. We hope that this issue will inspire and inform our readers and foster a spirit of unity and collaboration among pediatric anesthesiologists worldwide. This special issue on pediatric anesthesia is more than just a collection of articles; it is a call to action. It reminds us that in a world increasingly characterized by division, the pursuit of better health care, especially for children, remains a powerful uniting force. It challenges us to look beyond our differences and work together for a common cause. As we navigate these tumultuous times, let the field of pediatric anesthesia serve as a model for international collaboration, innovation, and a shared commitment to the well-being of all children. This editorial serves not just to highlight the milestones achieved but also to inspire continued efforts in bridging the divides, for the sake of every child who requires medical care, no matter where they are in the world. CTM and DK are sectional editors at the Journal of Pediatric Anesthesia. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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