Involvement of anesthesiologists in pediatric sedation and analgesia outside the operating room in Japan: is it too late, or is there still time?

The global COVID-19 pandemic highlighted significant existing supply-demand imbalances in anesthesia workforce, particularly impacting non-operating room anesthesia. Despite documented risks and mortality rates associated with pediatric procedural sedation and analgesia (PPSA) outside the operating room (OR), there is a pressing need for improvements in safety infrastructure. Comparative analysis with international practices reveals that anesthesiologists' involvement is associated with fewer adverse events and improved outcomes. However, lower reimbursement rate for sedation and anesthesia workforce shortage, and decentralized health resources are contributing factors to limit their participation in PPSA outside the OR in Japan. Enhancing the involvement of anesthesiologists through the public health frameworks such as "high-risk approach" and "population approach" can contribute to improvement of the safety and quality of PPSA. By tackling these challenges and implementing effective solutions, anesthesiologists can play a key role in ensuring safer and more effective PPSA outside the OR. Future challenges include enhancing training, addressing reduced clinical exposure due to work style reform, and developing effective educational systems. Research on improved educational approaches and fundamental outcome indices is crucial for improving PPSA practices outside the OR.