Effective communication with children is a skill, the importance of which is especially highlighted by the COVID-19 pandemic and the ubiquitous wearing of face masks. Anaesthesiology consultants have been shown to display excellent communication skills that facilitate the development of rapid rapport and patient cooperation. Good communication results in positive interactions for hospitalised children, which correlates with improved healthcare outcomes. However, interactions with a child aren’t always straightforward, particularly for trainees unfamiliar with certain communication techniques, which are important to use at a time when when the wearing of face masks is commonplace.

A 6‐day‐old, 4.0 kg neonate presented with intestinal malrotation, necessitating laparotomy. Intra‐operatively, an ultrasound‐guided erector spinae plane block was performed under general anesthesia with administration of 1 mg/kg levobupivacaine. Minutes following this, acute cardiac compromise was evident from a tapering end‐tidal carbon dioxide, falling oxygen saturations, and low blood pressure. Intravenous epinephrine 1 mcg/kg was administered, with some hemodynamic improvement. Intralipid (1.5 ml/kg) was given, with a return to normal hemodynamic parameters. This is the first case report of suspected local anesthetic toxicity in a neonate following an erector spinae plane block.

Cerebral near infrared spectroscopy (NIRS) monitoring has been extensively applied in neonatology and in cardiac surgery, becoming a standard in many pediatric cardiac centers. However, compensatory physiological mechanisms favor cerebral perfusion to the detriment of peripheral tissue oxygenation. Therefore, simultaneous measurement of cerebral and somatic oxygen saturation has been advocated to ease the differential diagnosis between central and peripheral sources of hypoperfusion, which may go undetected by standard monitoring and not mirrored by cerebral NIRS alone.

In this chapter we discuss the delivery of palliative care in the paediatric intensive care unit environment. Illustrated by challenging cases, we describe the role of intensive care in symptom management for the child with terminal or life-limiting illness. We detail the importance of a multidisciplinary team and their roles in the provision of individualised care for the child and their family. The importance of family-centred care and advance care planning is expanded upon. In addition, we explore end of life issues that are particular to children in intensive care such as withdrawal of life-sustaining therapies and organ donation. Finally, we discuss how to ensure the delivery of high-quality palliative care in the paediatric intensive care environment.

Background As advance healthcare directives gain clarity in state legislation in Ireland, anaesthesiologists will come across patients with resuscitation orders that will demand interpretation when encountered perioperatively. Studies show variable perceptions among anaesthesiologists towards the binding nature of resuscitation orders in the context of anaesthesia provision. Currently, knowledge, perceptions and practices of anaesthesiologists in Ireland towards such orders are not known. Methods A cross-sectional online survey was distributed to anaesthesiologists in adult teaching hospitals. Results In this cohort, 65.9% of those surveyed did not know if there was a local hospital policy advance healthcare directive containing, do not attempt resuscitation, decisions in the perioperative period in their current hospital; 57.7% did not know if there was a policy for not for resuscitation orders; 74.8% did not know if there are guidelines for the management of patients with resuscitation orders. Irrespective of the presence of an order stating otherwise, 43.9% would initiate resuscitation in the event of any arrest occurring in theatre, with 66.7% initiating resuscitation if secondary to iatrogenesis. Conclusions By uncovering low self-perceived levels of knowledge and mixed perceptions towards resuscitation orders, the authors hope that the study initiates much-needed conversations on the topic, particularly at a time when advance healthcare directives find a more firm legal footing in Ireland.