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                                                                                                                                                           'State-of the art'  in pediatric anesthesia is frequently defined and propagated at scientific meetings, congresses and in the literature in the form of expert lectures, opinions and reviews. However, economic pressures and lack of sometimes even basic staffing and logistic resources lead to situations  where supposedly low risk  anesthesia is conducted by insufficiently trained and inexperienced personal and  rapidly turns into high-risk anesthesia. It is of note that  some European countries (Denmark, Netherlands, and Switzer- land) necessitate 2 adequately qualified persons for induction and emergence of general anesthesia in children. This is in stark contrast to daily clinical practice in many other countries. In addition, anesthesia residents and fellows are frequently not supervised on a one-to-one basis or receive structured training and education. This results in 'survival' medicine rather than quality-focused perioperative pediatric anesthesia care. Exemplary programmes are, however, available. (The Scandinavian Society of Anesthesiology and Intensive Care Medicine) Health care payments for pediatric anesthesia are very unattractive in some countries resulting in cost cutting exercises by some independent anesthesia practitioners. These 'cost-savings' affect, but are not limited to, the provision of anesthetic assistants, equipment and medications. Children are often also scheduled together with adults on operating lists in larger hospitals and university centres, where professors and heads of surgical subspecialties dictate the scheduling. The principle of a dedicated pediatric unit is that the surgeon follows the child and not vice versa. This mixed scheduling also leads to dilution of experience and expertise even though the caseload (experience) of the anesthesiologist is well known to be one of the most critical factors in outcome. A recommended minimum yearly caseload for a pediatric anesthesiologist consists of 300 children up to ten years and 12 infants up to 6 months of age. (1) It is, therefore, not surprising that an annual case load of 0.7 general anesthetics in small children/per anesthesiologist leads to severe complications in 17%. (2) It is, however, surprising that anesthesia departments with less than 100-200 anesthetics in children per year ‘provide’ anesthesia in pre-term neonates and extensive surgical procedures driven by secondary motives. Clear strategies and recommendations for a best standard of clinical care are required. The ‘Who’, ’Where’, ‘When’ and ‘How’ need to be identified to achieve an optimal outcome for vulnerable children. (3,4) References 1. Lunn JN. Implications of the National Confidential Enquiry into Perioperative Deaths for pediatric anesthesia. Paediatr Anaesth. 1992; 2: 69–72. 2. Robert Fischer – Doctoral Thesis. University of Aachen; 2009. (urn:nbn:82-opus-15169) 3. Mudumbai SC, Honkanen A, Schmitt S et al. Variation of inpatient pediatric anesthesia in California from 2000–2009: a caseload and geographic        analysis. Paediatr Anaesth. 2014; 24:1295-301. 4. Harrison TE, Engelhardt T, MacFarlane F, Flick RP. Regionalization of pediatric anesthesia care: has the time come?     Paediatr Anaesth. 2014; 24: 897-8.
Safetots.org initiative addresses the gaps in regulations, teaching, supervision and research in pediatric anesthesia care.