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Albertz M, Ing RJ, Schwartz L, Navaratnam M. Error traps in patients with congenital heart disease undergoing noncardiac surgery. Paediatr Anaesth 2024; 34:1119-1129. [PMID: 39092610 DOI: 10.1111/pan.14971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.
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Affiliation(s)
- Megan Albertz
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Manchula Navaratnam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, California, USA
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2
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Kim EH, Park JB, Kang P, Ji SH, Jang YE, Lee JH, Kim JT, Kim HS. Effect of positive end expiratory pressure on non-hypoxic apnea time and atelectasis during induction of anesthesia in infant: A randomized controlled trial. Paediatr Anaesth 2024; 34:1146-1153. [PMID: 38980197 DOI: 10.1111/pan.14965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION This study aimed to assess the impact of positive-end-expiratory pressure (PEEP) on the non-hypoxic apnea time in infants during anesthesia induction with an inspired oxygen fraction of 0.8. METHODS This age stratified randomized controlled trial included patients under 1 year of age. Preoxygenation was performed using an inspired oxygen fraction of 0.8 for 2 min. Inspired oxygen fraction of 0.8 was administered via a face mask with volume-controlled ventilation at a tidal volume of 6 mL.kg-1, with or without 7 cmH2O of PEEP. Tracheal intubation was performed after 3 min of ventilation; however, it was disconnected from the breathing circuit. Ventilation was resumed once the pulse oximetry readings reached 95%. The primary outcome was the non-hypoxic apnea time, defined as the time from the cessation of ventilation to achieving a pulse oximeter reading of 95%. The secondary outcome measures included the degree of atelectasis assessed by ultrasonography and the presence of gastric air insufflation. RESULTS Eighty-four patients were included in the final analysis. In the positive end-expiratory pressure group, the atelectasis score decreased (17.0 vs. 31.5, p < .001; mean difference and 95% CI of 11.6, 7.5-15.6), while the non-hypoxic apnea time increased (80.1 s vs. 70.6 s, p = .005; mean difference and 95% CI of -9.4, -16.0 to -2.9), compared to the zero end-expiratory pressure group, among infants who are 6 months old or younger, not in those aged older than 6 months. DISCUSSION The application of positive end-expiratory pressure reduced the incidence of atelectasis and extended the non-hypoxic apnea time in infants who are 6 months old or younger. However, it did not affect the incidence of atelectasis nor the non-hypoxic apnea time in patients aged older than 6 months.
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Affiliation(s)
- Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Bin Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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3
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Dohrmann T, Gutsche N, Kramer R, Zeidler EM, Röher K, Wünsch VA, Dankert A, Krause L, Zöllner C, Sasu PB, Petzoldt M. Prospective development and validation of a universal classification for paediatric videolaryngoscopic tracheal intubation: the PeDiAC score. Anaesthesia 2024; 79:1201-1211. [PMID: 39108225 DOI: 10.1111/anae.16394] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 10/16/2024]
Abstract
BACKGROUND The VIDIAC score, a prospectively developed universal classification for videolaryngoscopy, has shown excellent diagnostic performance in adults. However, there is no reliable classification system for videolaryngoscopic tracheal intubation in children. We aimed to develop and validate a multivariable logistic regression model and easy-to-use score to classify difficult videolaryngoscopic tracheal intubation in children and to compare it with the Cormack and Lehane classification. A secondary aim was to externally validate the VIDIAC score in children. METHODS We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ videolaryngoscopes in all children undergoing tracheal intubation for elective surgical procedures. We validated the VIDIAC score externally and assessed its performance. We then identified eligible co-variables for inclusion in the PeDiAC score, developed a multivariable logistic regression model and compared its performance against the Cormack and Lehane classification. RESULTS We studied 809 children undergoing 904 episodes of tracheal intubation. The VIDIAC score outperformed the Cormack and Lehane classification when classifying the difficulty of videolaryngoscopic tracheal intubation, with an area under the receiver operating characteristic curve of 0.80 (95%CI 0.73-0.87) vs. 0.69 (95%CI 0.62-0.76), respectively, p = 0.018. Eight eligible tracheal intubation-related factors, that were selected by 100-times repeated 10-fold cross-validated least absolute shrinkage selector operator regression, were used to develop the PeDiAC model. The PeDiAC model and score showed excellent diagnostic performance and model calibration. The PeDiAC score achieved significantly better diagnostic performance than the Cormack and Lehane classification, with an area under the receiver operating characteristic curve of 0.97 (95%CI 0.96-0.99) vs. 0.69 (95%CI 0.62-0.76), respectively, p < 0.001. CONCLUSION We developed and validated a specifically tailored classification for paediatric videolaryngoscopic tracheal intubation with excellent diagnostic performance and calibration that outperformed the Cormack and Lehane classification.
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Affiliation(s)
- Thorsten Dohrmann
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nelly Gutsche
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Rilana Kramer
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Eva M Zeidler
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Röher
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Viktor A Wünsch
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - André Dankert
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip B Sasu
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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FitzGerald B, Jagannathan K, Burjek N, Rowland M. The development and benefits of a pediatric airway response team in a children's hospital. Semin Pediatr Surg 2024; 33:151453. [PMID: 39413487 DOI: 10.1016/j.sempedsurg.2024.151453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2024]
Affiliation(s)
- Brynn FitzGerald
- Department of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Krishna Jagannathan
- Department of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Nicholas Burjek
- Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Matthew Rowland
- Department of Critical Care Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611, USA; Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Sasu PB, Gutsche N, Kramer R, Röher K, Zeidler EM, Peters T, Köhl V, Krause L, Zöllner C, Dohrmann T, Petzoldt M. Universal paediatric videolaryngoscopy and glottic view grading: a prospective observational study. Anaesthesia 2024; 79:1062-1071. [PMID: 38989863 DOI: 10.1111/anae.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first-choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children. METHODS We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six-stage grading system. RESULTS There were 904 tracheal intubations in 809 children over a 16-month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway-related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59-0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73-0.87) for the direct glottic view during laryngoscopy (p = 0.005). CONCLUSIONS Universal, first-choice videolaryngoscopy reduced substantially the incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children.
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Affiliation(s)
- Phillip B Sasu
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nelly Gutsche
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Rilana Kramer
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Röher
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Eva M Zeidler
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tanja Peters
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Vera Köhl
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Dohrmann
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Hu PY, Chang YT, Yang ST, Wu CS, Cheng KI, Su MP. Comparison of supraglottic airway device and endotracheal tube in former preterm infants receiving general anesthesia: a randomized controlled trial. Sci Rep 2024; 14:19579. [PMID: 39179661 PMCID: PMC11343740 DOI: 10.1038/s41598-024-69950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 08/12/2024] [Indexed: 08/26/2024] Open
Abstract
To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT.
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Affiliation(s)
- Pin-Yang Hu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Tang Chang
- Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Ting Yang
- Division of Neonatology, Department of Pediatric, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Shu Wu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Miao-Pei Su
- Department of Anesthesiology, Kaohsiung Medical University Gangshan Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Schneck E, Knittel F, Markmann M, Balzer F, Rubarth K, Zajonz T, Schreiner AL, Hecker A, Naehrlich L, Koch C, Laffolie JD, Sander M. Assessment of risk factors for adverse events in analgosedation for pediatric endoscopy: A 10-year retrospective analysis. J Pediatr Gastroenterol Nutr 2024; 79:382-393. [PMID: 38873914 DOI: 10.1002/jpn3.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES Data regarding the occurrence of complications specifically during pediatric anesthesia for endoscopic procedures is limited. By evaluating such data, factors could be identified to assure proper staffing and preparation to minimize adverse events and improve patient safety during flexible endoscopy. METHODS This retrospective cohort study included children undergoing anesthesia for gastroscopy, colonoscopy, bronchoscopy, or combined endoscopic procedures over 10-year period. The primary study aim was to evaluate the incidence of complications and identify risk factors for adverse events. RESULTS Overall, 2064 endoscopic procedures including 1356 gastroscopies (65.7%), 93 colonoscopies (4.5%), 235 bronchoscopies (11.4%), and 380 combined procedures (18.4%) were performed. Of the 1613 patients, 151 (7.3%) patients exhibited an adverse event, with respiratory complications being the most common (65 [3.1%]). Combination of gastrointestinal endoscopies did not lead to an increased adverse event rate (gastroscopy: 5.5%, colonoscopy: 3.2%). Diagnostic endoscopy as compared to interventional had a lower rate. If bronchoscopy was performed, the rate was similar to that of bronchoscopy alone (19.5% vs. 20.4%). Age < 5.8 years or body weight less than 20 kg, bronchoscopy, American Society of Anesthesiologists status ≥ 2 or pre-existing anesthesia-relevant diseases, and urgency of the procedure were independent risk factors for adverse events. For each risk factor, the risk for events increased 2.1-fold [1.8-2.4]. CONCLUSIONS This study identifies multiple factors that increase the rate of adverse events associated anesthesia-based endoscopy. Combined gastrointestinal procedures did not increase the risk for adverse events while combination of bronchoscopy to gastrointestinal endoscopy showed a similar risk as bronchoscopy alone.
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Affiliation(s)
- Emmanuel Schneck
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Fabienne Knittel
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Melanie Markmann
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Humboldt University, Berlin, Germany
| | - Thomas Zajonz
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Anna-Lena Schreiner
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Lutz Naehrlich
- Department of General Pediatrics and Neonatology, University of Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Jan de Laffolie
- Department of General Pediatrics and Neonatology, University of Giessen, Giessen, Germany
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
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Petrov I, Stankovic Z, Soldatovic I, Tomic A, Simic D, Milenovic M, Milovanovic V, Nikolic D, Jovicic N. Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features. J Clin Med 2024; 13:4294. [PMID: 39124561 PMCID: PMC11313502 DOI: 10.3390/jcm13154294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Prediction of a difficult airway during pre-anesthetic evaluation is of great importance because it enables an adequate anesthetic approach and airway management. As there is a scarcity of prospective studies evaluating the role of anthropometric measures of the face and neck in predicting difficult airways in infants with an apparently normal airway, we aimed to identify the aforementioned predictors of difficult facemask ventilation and intubation in infants. Methods: A prospective, observational study that included 97 infants requiring general endotracheal anesthesia was conducted. Anthropometric and specific facial measurements were obtained before ventilation and intubation. Results: The incidence of difficult facemask ventilation was 15.5% and 38.1% for difficult intubation. SMD (sternomental distance), TMA (tragus-to-mouth angle distance), NL (neck length) and mouth opening were significantly lower in the difficult facemask ventilation group. HMDn (hyomental distance in neutral head position), HMDe (hyomental distance in neck extension), TMD (thyromental distance), SMD, mandibular development and mouth opening were significantly different in the intubation difficulty group compared to the non-difficult group. HMDn and HMDe showed significantly greater specificities for difficult intubation (83.8% and 76.7%, respectively), while higher sensitivities were observed in TMD, SMD and RHSMD (ratio of height to SMD) (89.2%, 75.7%, and 70.3%, respectively). Regarding difficult facemask ventilation, TMA showed greater sensitivity (86.7%) and SMD showed greater specificity (80%) compared to other anthropometric parameters. In a multivariate model, BMI (body mass index), COPUR (Colorado Pediatric Airway Score), BOV (best oropharyngeal view) and TMA were found to be independent predictors of difficult intubation, while BMI, ASA (The American Society Physical Status Classification System), CL (Cormack-Lehane Score), TMA and SMD predicted difficult facemask ventilation. Conclusions: Preoperative airway assessment is of great importance for ventilation and intubation. Patient's overall condition and facial measurements can be used as predictors of difficult intubation and ventilation.
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Affiliation(s)
- Ivana Petrov
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Zorana Stankovic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Ana Tomic
- University Clinical Centre of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Dusica Simic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Miodrag Milenovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
- University Clinical Centre of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Vladimir Milovanovic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Dejan Nikolic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
| | - Nevena Jovicic
- University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia; (Z.S.); (D.S.); (V.M.); (D.N.); (N.J.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (I.S.); (M.M.)
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9
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Kaufmann J, Huber D, Engelhardt T, Kleine-Brueggeney M, Kranke P, Riva T, von Ungern-Sternberg BS, Fuchs A. [Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]. DIE ANAESTHESIOLOGIE 2024; 73:473-481. [PMID: 38958671 PMCID: PMC11222175 DOI: 10.1007/s00101-024-01424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.
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Affiliation(s)
- Jost Kaufmann
- Kinderkrankenhaus der Kliniken der Stadt Köln gGmbH, Amsterdamer Str. 59, 50735, Köln, Deutschland.
- Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland.
| | - Dennis Huber
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Thomas Engelhardt
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Kanada
| | - Maren Kleine-Brueggeney
- Klinik für Kardioanästhesiologie und Intensivmedizin, Deutsches Herzzentrum der Charité (DHZC), Berlin, Deutschland
- Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Thomas Riva
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australien
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australien
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, WA, Australien
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australien
| | - Alexander Fuchs
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
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10
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Trinh SH, Tövisházi G, Kátai LK, Bogner LL, Maka E, Balog V, Szabó M, Szabó AJ, Gál J, Jermendy Á, Hauser B. Airway management may influence postoperative ventilation need in preterm infants after laser eye treatment. Pediatr Res 2024:10.1038/s41390-024-03356-4. [PMID: 38909156 DOI: 10.1038/s41390-024-03356-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Retinopathy of prematurity is treated with laser photocoagulation under general anaesthesia with intubation using endotracheal tube (ETT), which carries a risk for postoperative mechanical ventilation (MV). Laryngeal mask airway (LMA) may provide a safe alternative. We assessed the need for postoperative MV in preterm infants who received LMA versus ETT. METHODS In this single-centre, retrospective cohort study, preterm infants who underwent laser photocoagulation between 2014-2021 were enroled. For airway management, patients received either LMA (n = 224) or ETT (n = 47). The outcome was the rate of postoperative MV. RESULTS Patients' age were 37 [35;39] weeks of postmenstrual age, median bodyweight of Group LMA was higher than Group ETT's (2110 [1800;2780] g versus 1350 [1230;1610] g, respectively, p < 0.0001). After laser photocoagulation, 8% of Group LMA and 74% of Group ETT left the operating theatre requiring MV. Multiple logistic regression revealed that the use of LMA and every 100 g increase in bodyweight significantly decreased the odds of mechanical ventilation (OR 0.21 [95% CI 0.07-0.60], and 0.73 [95% CI 0.63-0.84], respectively). Propensity score matching confirmed that LMA decreased the odds of postoperative MV (OR 0.30 [95% CI 0.11-0.70]). CONCLUSION The use of LMA is associated with a reduced need for postoperative MV. IMPACT Using laryngeal mask airway instead of endotracheal tube for airway management in preterm infants undergoing general anaesthesia for laser photocoagulation for treating retinopathy of prematurity could significantly decrease the postoperative need for mechanical ventilation. According to our current understanding, this has been the largest study investigating the effect of laryngeal mask airway during general anaesthesia in preterm infants. Our study suggests that the use of laryngeal mask airway is a viable alternative to intubation in the vulnerable population of preterm infants in need of laser treatment.
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Affiliation(s)
- Sarolta H Trinh
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Gyula Tövisházi
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Institute of Anaesthesiology and Perioperative Care, Semmelweis University, Budapest, Hungary
| | - Lóránt K Kátai
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Luca L Bogner
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Erika Maka
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Vera Balog
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Miklós Szabó
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Attila J Szabó
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - János Gál
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Ágnes Jermendy
- Department of Neonatology, Paediatric Centre, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Balázs Hauser
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
- Institute of Anaesthesiology and Perioperative Care, Semmelweis University, Budapest, Hungary.
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11
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Cui Y. What should be prepared for neonates with potentially difficult airway? Asian J Surg 2024; 47:2829-2830. [PMID: 38395713 DOI: 10.1016/j.asjsur.2024.02.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Affiliation(s)
- Yu Cui
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China.
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12
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Shen C, Shi Y. The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study. J Craniofac Surg 2024; 35:1192-1196. [PMID: 38578083 DOI: 10.1097/scs.0000000000010114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/28/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Difficult airway remains a great challenge in pediatric anesthesia practice. Previously published data show the prevalence of difficult airways in pediatric population varies in a wide range. However, there is a lack of studies in the Asian region. METHODS This cross-sectional single-center study was conducted in a tertiary pediatric hospital in China from October 2022 to October 2023. The patients who underwent elective surgery under general anesthesia with tracheal intubation were recruited consecutively. Data on patient characteristics, airway assessment, and airway management information were collected. Multivariable logistic regression analysis was performed to detect the independent variables of difficult airway in pediatric patients. RESULTS A total of 18,491 pediatric patients were included in this study. The overall incidence of difficult airways was 0.22%, 39% of whom were unanticipated. Very few previous airway management information was available in the patients presented with a known difficult airway. Patients with younger age, higher American Society of Anesthesiologists (ASA) physical status classification grade, and presented for craniofacial and thoracic surgery were associated with higher incidence of difficult airway. Further multivariable logistic regression analysis revealed that age ≤28 days (OR=50.48), age between 28days and 1 year (OR=6.053), craniofacial surgery (OR=1.81), and thoracic surgery (OR=0.2465) were independent risk factors of increased incidence of difficult airway. CONCLUSIONS Our study showed the prevalence of difficult airways in pediatric surgical patients. Patient characteristics, age, and type of surgery were identified as the independent factors associated with increased occurrence of difficult airways. Unanticipated difficult airway was not unusual in our study population, even for the patients with previous surgical history.
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Affiliation(s)
- Chen Shen
- Department of Anesthesiology, Children's Hospital of Fudan University, Minhang District, Shanghai, China
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13
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Disma N, Habre W, Veyckemans F. Lessons learned from big data (APRICOT, NECTARINE, PeDI). Best Pract Res Clin Anaesthesiol 2024; 38:111-117. [PMID: 39445556 DOI: 10.1016/j.bpa.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 10/25/2024]
Abstract
Big data in paediatric anaesthesia allows the evaluation of morbidity and mortality of anaesthesia in a large population, but also the identification of rare critical events and of their causes. This is a major step to focus education and design clinical guidelines. Moreover, they can help trying to determine normative data in a population with a wide range of ages and body weights. The example of blood pressure under anaesthesia will be detailed. Big data studies should encourage every department of anaesthesia to collect its own data and to benchmark its performance by comparison with published data. The data collection processes are also an opportunity to build collaborative research networks and help researchers to complete multicentric studies. Up to recently, big data studies were only performed in well developed countries. Fortunately, big data collections have started in some low and middle income countries and truly international studies are ongoing.
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy.
| | - Walid Habre
- Medical Faculty, University of Geneva, Geneva, OK, Switzerland.
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14
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Cook TM, Oglesby F, Kane AD, Armstrong RA, Kursumovic E, Soar J. Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia 2024; 79:368-379. [PMID: 38031494 DOI: 10.1111/anae.16187] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists.
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Affiliation(s)
- T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- School of Medicine, University of Bristol, Bristol, UK
| | - F Oglesby
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - A D Kane
- Department of Anaesthesia, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, UK
- Royal College of Anaesthetists, London, UK
| | - R A Armstrong
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Royal College of Anaesthetists, London, UK
| | - E Kursumovic
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Royal College of Anaesthetists, London, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
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15
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Rebollar RE, Hierro PL, Fernández AMMA. Delayed Sequence Intubation in Children, Why Not? SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:117-124. [PMID: 38764564 PMCID: PMC11098273 DOI: 10.4103/sjmms.sjmms_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | - Paula Lozano Hierro
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
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16
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Riva T, Goerge S, Fuchs A, Greif R, Huber M, Lusardi AC, Riedel T, Ulmer FF, Disma N. Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model. Paediatr Anaesth 2024; 34:225-234. [PMID: 37950428 DOI: 10.1111/pan.14796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Rapid-sequence tracheotomy and scalpel-bougie tracheotomy are two published approaches for establishing emergency front-of-neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches. AIMS The aim of this cross-over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques. METHODS Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front-of-neck access using one and then the other technique: rapid-sequence tracheotomy and scalpel-bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation. RESULTS The median duration of the scalpel-bougie tracheotomy was 48 s (95% CI: 37-57), while the duration of the rapid-sequence tracheotomy was 59 s (95% CI: 49-66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: -4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%-98.2%). The scalpel-bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants. CONCLUSIONS The scalpel-bougie tracheotomy was slightly faster than the rapid-sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel-bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05499273.
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Affiliation(s)
- Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Goerge
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
- University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Riedel
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Francis F Ulmer
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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17
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Stein ML, Sarmiento Argüello LA, Staffa SJ, Heunis J, Egbuta C, Flynn SG, Khan SA, Sabato S, Taicher BM, Chiao F, Bosenberg A, Lee AC, Adams HD, von Ungern-Sternberg BS, Park RS, Peyton JM, Olomu PN, Hunyady AI, Garcia-Marcinkiewicz A, Fiadjoe JE, Kovatsis PG. Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time. EClinicalMedicine 2024; 69:102461. [PMID: 38374968 PMCID: PMC10875248 DOI: 10.1016/j.eclinm.2024.102461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/21/2024] Open
Abstract
Background The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding None.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Julia Heunis
- Department of Pediatrics, Boston Children’s Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chinyere Egbuta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen G. Flynn
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A. Khan
- Department of Anesthesiology, UTHealth - McGovern Medical School, Houston, TX, USA
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children’s Hospital, and Anaesthesia Research Group, Murdoch Children’s Research Institute, Parkville, Australia
| | - Brad M. Taicher
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, USA
| | - Adrian Bosenberg
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Angela C. Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H. Daniel Adams
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Britta S. von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children’s Hospital, Institute for Paediatric Perioperative Excellence, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perioperative Medicine Team, Perioperative Care Program, and Telethon Kids Institute, Perth, Australia
| | - Raymond S. Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - James M. Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Patrick N. Olomu
- Department of Pediatric Anesthesiology and Pain Management, Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Agnes I. Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - John E. Fiadjoe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Pete G. Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
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18
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Fuchs A, Koepp G, Huber M, Aebli J, Afshari A, Bonfiglio R, Greif R, Lusardi AC, Romero CS, von Gernler M, Disma N, Riva T. Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis. Br J Anaesth 2024; 132:392-406. [PMID: 38030551 DOI: 10.1016/j.bja.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/03/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children. METHODS This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation. RESULTS After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration. CONCLUSION This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range. CLINICAL TRIAL REGISTRATION Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Gabriela Koepp
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Aebli
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Arash Afshari
- Department of Paediatric And Obstetric Anesthesia, Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Institute of Clinical Medicine, Copenhagen, Denmark
| | - Rachele Bonfiglio
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria; University of Bern, Bern, Switzerland
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina S Romero
- Anesthesia, Critical Care and Pain Department, Hospital General Universitario De Valencia, Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | | | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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19
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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20
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Senger A, Irouschek A, Weber M, Lutz R, Rompel O, Kesting M, Schmidt J. Airway management in a two-year-old child with a tongue tumor using video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation (hybrid technique). Clin Case Rep 2024; 12:e8425. [PMID: 38197059 PMCID: PMC10774545 DOI: 10.1002/ccr3.8425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/27/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
Airway management in children can be challenging. A hybrid technique using a video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation allowed a successful airway management in a two-year-old child with a large tongue tumor.
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Affiliation(s)
- Anne‐Sophie Senger
- Department of AnesthesiologyUniversity Hospital Erlangen, Faculty of Medicine, Friedrich Alexander‐Universität Erlangen‐NürnbergErlangenGermany
| | - Andrea Irouschek
- Department of AnesthesiologyUniversity Hospital Erlangen, Faculty of Medicine, Friedrich Alexander‐Universität Erlangen‐NürnbergErlangenGermany
| | - Manuel Weber
- Department of Oral and Maxillofacial SurgeryUniversity Hospital Erlangen, Faculty of Medicine, Friedrich‐Alexander‐Universität Erlangen‐NürnbergErlangenGermany
| | - Rainer Lutz
- Department of Oral and Maxillofacial SurgeryUniversity Hospital Erlangen, Faculty of Medicine, Friedrich‐Alexander‐Universität Erlangen‐NürnbergErlangenGermany
| | - Oliver Rompel
- Institute of Radiology, University Hospital Erlangen, Faculty of Medicine, Friedrich‐Alexander‐Universität Erlangen‐NürnbergErlangenGermany
| | - Marco Kesting
- Department of Oral and Maxillofacial SurgeryUniversity Hospital Erlangen, Faculty of Medicine, Friedrich‐Alexander‐Universität Erlangen‐NürnbergErlangenGermany
| | - Joachim Schmidt
- Department of AnesthesiologyUniversity Hospital Erlangen, Faculty of Medicine, Friedrich Alexander‐Universität Erlangen‐NürnbergErlangenGermany
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21
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Massimiliano S, Daniele T. From Brobdingnag to Lilliput: Gulliver's travels in airway management guidelines. Br J Anaesth 2024; 132:21-24. [PMID: 38036322 DOI: 10.1016/j.bja.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Neonatal airway management comes with exclusive anatomical, physiological, and environmental complexities, and probably higher incidences of accidents and complications. No dedicated airway management guidelines were available until the recently published first joint guideline released by a task force supported by the European Society of Anaesthesiology and Intensive Care and the British Journal of Anaesthesia and focused on airway management in children under 1 yr of age. The guideline offers a series of recommendations based on meticulous methodology including multiple Delphi rounds to complement the sparse and scarce available evidence. Getting back from Brobdingnag, the land of giants with many guidelines available, this guideline represents a foundational cornerstone in the land of Lilliput.
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Affiliation(s)
- Sorbello Massimiliano
- Head of Anesthesia and Intensive Care, Department of Anaesthesia "Giovanni Paolo II" Hospital, Ragusa, Italy.
| | - Trevisanuto Daniele
- Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
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22
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
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23
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Dong W, Zhang W, Er J, Liu J, Han J. Comparison of laryngeal mask airway and endotracheal tube in general anesthesia in children. Exp Ther Med 2023; 26:554. [PMID: 37941592 PMCID: PMC10628640 DOI: 10.3892/etm.2023.12253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/09/2023] [Indexed: 11/10/2023] Open
Abstract
At present, there is no relevant expert consensus indicating which ventilation device is more efficient for general anesthesia. The present literature review and meta-analysis compared the effects of the laryngeal mask airway and endotracheal intubation on airway complications during general anesthesia. The keywords 'laryngeal mask airway', 'endotracheal tube', 'tracheal tube', 'children', 'pediatric', 'anesthesia', 'randomized controlled trials' (RCTs) and 'randomized' were used to perform the literature search in PubMed. Quality assessment was performed by two reviewers according to domains defined by the Cochrane Collaboration tool. Data extraction, risk of bias assessment and quality of evidence assessment were performed with the Cochrane tool. A total of 16 RCTs were included. The results indicated that the effects of the laryngeal mask airway group on heart rate variability [mean difference=-13.76; 95% CI, -18.19-(-9.33); P<0.00001], the incidence of hypoxemia [odds ratio (OR)=0.52; 95% CI, 0.28-0.97; P=0.04] and the incidence of postoperative cough (OR=0.22; 95% CI, 0.12-0.40; P<0.0001) were significantly lower than those of the endotracheal intubation group. The success rate of one-time implantation in the laryngeal mask airway group was significantly higher than that noted in the endotracheal intubation group (OR=0.20; 95% CI, 0.07-0.59; P=0.003). However, no significant differences were noted between the two groups in bronchospasm, sore throat, mucosal injury, nausea and vomiting and reflux aspiration. In conclusion, the results indicated that laryngeal mask airway application can reduce complications during general anesthesia compared with endotracheal intubation.
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Affiliation(s)
- Wei Dong
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Jianxu Er
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Jiapeng Liu
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin 300222, P.R. China
| | - Jiange Han
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin 300222, P.R. China
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24
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Abstract
PURPOSE OF REVIEW The aim of this article is to briefly review the pediatric ambulatory surgery landscape, identify two of the most common comorbidities affecting this population, examine the influence of pediatric obesity and sleep disordered breathing (SDB)/obstructive sleep apnea (OSA) on perioperative care, and provide information that can be used when formulating site specific criteria for ambulatory surgical centers. RECENT FINDINGS Most pediatric surgeries performed are now ambulatory, a majority of which take place outside of academic centers. Children with comorbidities such as obesity and SDB/OSA are undergoing surgical or diagnostic procedures which were previously deemed unacceptable for ambulatory surgery. The increase in pediatric ambulatory surgery coupled with a recent shortage of pediatric anesthesiologists means many children will receive anesthesia care from general clinicians who care for children intermittently and may be unfamiliar with the perioperative risks these comorbidities can present. SUMMARY Our pediatric ambulatory surgical population is anticipated to demonstrate increasing rates of obesity and SDB/OSA. Bringing attention to potential perioperative complications associated with these comorbidities provides a stronger foundation upon which to formulate criteria for individual ambulatory centers. It allows for targeted anesthetic management, influences provider assignments and/or staffing ratios, and informs scheduling times. For anesthesiologists who do not practice pediatric anesthesia daily, knowing what to anticipate plays a significant role in the ability to eliminate surprises and care for these patients safely.
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Affiliation(s)
- Audra M Webber
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Marjorie Brennan
- Department of Anesthesiology, Pain and Perioperative Medicine, The George Washington University School of Medicine, Children's National Hospital, Washington, District of Columbia, USA
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25
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Liu X, Han F, Zhang L, Xia Y, Sun Y. Value of the Hyomental Distance Measured With Ultrasound in Forecasting Difficult Laryngoscopy in Newborns. J Perianesth Nurs 2023; 38:860-864. [PMID: 37389502 DOI: 10.1016/j.jopan.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Preoperative evaluations of difficult airways are imperative, especially in newborns. The hyomental distance is a reliable index for predicting difficult airways in adults. However, few studies have evaluated the value of the hyomental distance for predicting difficult airways in newborns. It is unclear whether the hyomental distance forecasts a restricted or difficult view when using direct laryngoscopy. We intended to develop an effective system for predicting difficult tracheal intubation in newborns. DESIGN A prospective observational clinical study. METHODS Newborns aged 0 to 28 days undergoing oral endotracheal intubation with direct laryngoscopy for elective surgery under general anesthesia were enrolled. The hyomental distance and hyoid level tissue thickness were assessed by ultrasound. Other parameters, such as the mandibular length and sternomental distance, were also evaluated before anesthesia. The glottic structure view under laryngoscopy was graded according to the Cormack-Lehane classification. The patients with Grade 1 and 2 laryngeal views were assigned to Group E. Those with Grade 3 and 4 views were assigned to Group D. FINDINGS A total of 123 newborns were recruited for our study. The incidence of poor visualization of the larynx during laryngoscopy in our study was 10.6%. The multifactor logistic regression results showed that the hyomental distance was a powerful predictor of difficult laryngoscopy (OR = 0.16, 95% CI 0.03-0.74, P = .019). The curve with the highest sensitivity and specificity and the maximum area under the curve (AUC) was the hyomental distance. The receiver operating characteristic (ROC) curve for the hyomental distance suggested that the best cut-off value was less than equal to 2.74 cm, with an AUC of 0.80 (95% CI 0.64-0.95). CONCLUSIONS It is noninvasive and feasible to accurately measure the hyomental distance with ultrasound in newborns, and the results are reliable. We believe that the hyomental distance measured with ultrasound could be used as a marker for predicting difficult laryngoscopy in newborns.
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Affiliation(s)
- Xinghui Liu
- Department of Anaesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui Province, China
| | - Fen Han
- Department of Anaesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui Province, China
| | - Lingli Zhang
- Department of Anaesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui Province, China
| | - Yin Xia
- Department of Anaesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui Province, China
| | - Yingying Sun
- Department of Anaesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui Province, China.
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26
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Ilala TT, Teku Ayano G, Seife MA, Yinges Kebede M, Geleta BA, Tamrat Yilma K. Prevalence of Bradycardia After Induction of General Anesthesia and Associated Factors Among Surgical Pediatric Patients. A Prospective Observational Study. Pediatric Health Med Ther 2023; 14:419-434. [PMID: 37954533 PMCID: PMC10637223 DOI: 10.2147/phmt.s429321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
Background Heart rate is the main determinant factor of the child's cardiac output in the first year of life. Thus, bradycardia decreases cardiac output leading to fatal cardiac arrhythmias, cardiac arrest, and even death. The objective of this study is to determine the prevalence of bradycardia and its associated factors after induction of general anesthesia among pediatric patients operated at Hawassa University Comprehensive Specialized Hospital (HUCSH). Methods Prospective observational study was employed at HUCSH by using a systematic random sampling technique. Pediatric surgical patients less than 6 years old were included in the study. Data were entered into Epi data statistical software (version 4.6.0.) and exported to SPSS (version 25.0). Categorical data were analyzed using chi-square statistics, and continuous data were analyzed using Student's t-test. Bivariable logistic regression was used to select candidate variables for multivariable logistic regression. Results The prevalence of bradycardia among 205 pediatric patients included in this study was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (halothane), difficult intubation, intraoperative complications, and significant surgical blood loss were independently associated with bradycardia. Conclusion The prevalence of bradycardia after induction of general anesthesia was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (particularly with halothane), difficult intubation, intraoperative complications such as hypoxia, and significant blood loss were significantly associated with bradycardia.
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Affiliation(s)
- Tajera Tageza Ilala
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Gudeta Teku Ayano
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Minda Abebe Seife
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Mengistu Yinges Kebede
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Belete Alemu Geleta
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Kidanemariam Tamrat Yilma
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
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27
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Yousef N, Soghier L. Neonatal airway management training using simulation-based educational methods and technology. Semin Perinatol 2023; 47:151822. [PMID: 37778883 DOI: 10.1016/j.semperi.2023.151822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.
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Affiliation(s)
- Nadya Yousef
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, Paris-Saclay University Hospitals, APHP, Paris, France
| | - Lamia Soghier
- Children's National Hospital, Washington, DC, United States; The George Washington University School of Medicine and Health Sciences, United States.
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28
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Abstract
Safe and effective management of the neonatal airway requires knowledge, teamwork, preparation and experience. At baseline, the neonatal airway can present significant challenges to experienced neonatologists and paediatric anaesthesiologists, and increased difficulty can be due to anatomical abnormalities, physiological instability or increased situational stress. Neonatal airway obstruction is under recognised, and should be considered an emergency until the diagnosis and physiological implications are understood. When multiple types of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases exponentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach will help to reduce errors and morbidity.
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Affiliation(s)
- Toby Kane
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Department of Neonatology, Royal Children's Hospital, Parkville, Australia.
| | - Anastasia Pellicano
- Department of Neonatology, Royal Children's Hospital, Parkville, Australia; Paediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Parkville, Australia
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Australia; Anaesthetics, Murdoch Children's Research Institute, Parkville, Australia
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29
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Sawyer T, Yamada N, Umoren R. The difficult neonatal airway. Semin Fetal Neonatal Med 2023; 28:101484. [PMID: 38000927 DOI: 10.1016/j.siny.2023.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.
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Affiliation(s)
- Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Nicole Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Irouschek A, Moritz A, Kremer S, Fuchte T, Danzl A, Schmidt J, Golditz T. An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists. PLoS One 2023; 18:e0288816. [PMID: 37535590 PMCID: PMC10399777 DOI: 10.1371/journal.pone.0288816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS. METHODS For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. 'Time-to-vocal-cords', 'time-to-intubate', 'time-to-ventilate', the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded. RESULTS A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the 'time-to-intubate' or 'time-to-ventilate'. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating. CONCLUSIONS Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.
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Affiliation(s)
- Andrea Irouschek
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Moritz
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sven Kremer
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Fuchte
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Anja Danzl
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Joachim Schmidt
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Golditz
- Department of Anesthesiology, Faculty of Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Hansen TG, Vieri J, Børke WB, Castellheim AG. Outcome following anaesthesia in infancy in the Nordic countries: Subgroup analysis of the NECTARINE study. Acta Anaesthesiol Scand 2023; 67:714-723. [PMID: 36918742 DOI: 10.1111/aas.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION The neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective observational study reported an incidence of 35.2% of critical events requiring intervention during 6542 anaesthetics in 5609 infants up to 60 weeks postmenstrual age (PMA) from 165 centres in 31 European countries. METHODS Sub-analysis of the cohort from the Nordic countries (8% of the entire cohort) was conducted. Secondary aims were to describe the Nordic countries' anaesthetic practices and compare morbidity and mortality with the overall European cohort. RESULTS Eleven Nordic centres recruited 447 infants (66% males, 37.3% born preterm and 45% had congenital anomalies) undergoing anaesthesia for 530 surgical or non-surgical procedures at 25-60 weeks PMA. Perioperative critical events triggered interventions in 228/530 (43%) cases. Hypotension (12.6%) or hypoxaemia (11.7%) were more common in younger patients and those with co-morbidities. Hypo/hypercapnia occurred in 1.5%/4.7% of cases. More than two attempts for intubation were required in 13 (2.9%) infants (max three attempts). Distribution of ASA-Physical Status Scores was similar to the total European cohort (40% was ASA > 2). A total of 236/530 (44.5%) patients were admitted to the postoperative intensive care unit. Thirty-day morbidity (complications in 87/447 = 19.5%) and mortality (8/447, 1.8%) did not differ from the overall European cohort. Hospital re-admissions were significant up to 90 days (98/447 = 21.9%). CONCLUSIONS In Nordic countries, anaesthesia in young infant children is resource-demanding, and perioperative critical events and co-morbidities are common. Thirty-day morbidity and mortality data in the Nordic countries did not differ from the overall European cohort.
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Affiliation(s)
- Tom G Hansen
- Department of Anaesthesiology and Intensive Care - Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Jenny Vieri
- Department of Prehospital Emergency Care, Pain Management and Anaesthesiology, Tampere University Hospital, Tampere, Finland
| | - Wenche Bakken Børke
- Division of Emergencies and Critical Care Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Albert Gyllencreutz Castellheim
- Department of Anaesthesiology and Intensive Care Medicine, Queen Silvia Children Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Masui K, Asai T, Saito T, Okuda Y. Efficacy of McGRATH®MAC videolaryngoscope blade 1 for tracheal intubation in small children: a randomized controlled clinical study. J Anesth 2023:10.1007/s00540-023-03207-2. [PMID: 37311898 DOI: 10.1007/s00540-023-03207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/29/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Videolaryngoscopes may not be as effective in small children as they are in older children and in adults. The size 1 blade is commercially available for the McGRATH®MAC videolaryngoscope (Covidien, Medtronic, Tokyo, Japan), but its efficacy in comparison with a Macintosh laryngoscope blade 1 is not known. AIM The main aim of this study was to assess the efficacy of McGrath®MAC blade 1 in comparison with a conventional Macintosh laryngoscope blade 1, in children aged less than 24 months. METHODS Thirty-eight children aged less than 24 months were randomly allocated to one of two groups, and tracheal intubation was attempted using either a direct laryngoscope with a Macintosh blade 1 or a videolaryngoscope with a McGRATH®MAC blade 1. In another 12 children aged 2-4 years, the same comparisons were made with blade 2. The primary outcome measure was time to tracheal intubation using a size 1 blade. RESULTS Tracheal intubation took significantly longer with a McGRATH®MAC blade 1 (median (interquartile range): 38.0 (31.8-43.5) s) than with the Macintosh blade 1(27.4 (25.9-29.2) s) (p < 0.0001; median difference (95% CI for the median difference): 10.6 (6.4-14.0) s), mainly due to difficulty in advancing a tube into the trachea. No significant difference was observed for the size 2. CONCLUSIONS In small children without predicted difficult airways, time to intubate the trachea was significantly longer for a McGRATH®MAC blade 1 than a Macintosh blade 1. CLINICAL TRIAL REGISTRATION jRCT1032220366.
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Affiliation(s)
- Katsuhide Masui
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan
| | - Tomoyuki Saito
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan
| | - Yasuhisa Okuda
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya City, Saitama, 343-8555, Japan
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Disma N, Asai T. Preventing difficult facemask ventilation in children: all is well that starts well. Br J Anaesth 2023:S0007-0912(23)00190-3. [PMID: 37183099 DOI: 10.1016/j.bja.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 05/16/2023] Open
Abstract
Difficult facemask ventilation at induction of general anaesthesia can trigger hypoxaemia and inadequate ventilation if not immediately identified and adequately treated. For this reason, identification of predisposing conditions before induction of anaesthesia and causes of poor facemask ventilation are critical to avoid the subsequent complications. In a recently published secondary analysis of the Paediatric Difficult Intubation (PeDI) registry, the incidence and risk factors for difficult facemask ventilation in children with difficult tracheal intubation was described, as highlighted in the editorial.
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Centre, Koshigaya, Saitama, Japan
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Isogai H, Kojima T, Kako H. Fiberoptic Intubation vs. Video-Assisted Fiberoptic Intubation in a High-Fidelity Pediatric Simulator: A Randomized Controlled Trial. Cureus 2023; 15:e39280. [PMID: 37346217 PMCID: PMC10280038 DOI: 10.7759/cureus.39280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Life-threatening hypoxemia during tracheal intubation is more likely to occur in children than adults due to its unique physiological and anatomical nature. Fiberoptic intubation is widely performed in children with difficult airways. However, mastery of fiberoptic intubation requires substantial training, and novice trainees need to attempt fiberoptic intubation in children at high risk of respiratory-related adverse events. Therefore, a safer method than traditional fiberoptic intubation for children with difficult airways is desirable for novice anesthesia trainees. This study aimed to compare the efficacy of video-assisted fiberoptic intubation (VAFI) with that of traditional fiberoptic intubation (FOI) in a high-fidelity pediatric simulator by medical professionals with no experience in tracheal intubation. METHOD This randomized, controlled, simulation-based study was conducted in a tertiary-care pediatric hospital. Registered nurses working in the operating room were enrolled in this study and randomly assigned to either the FOI or VAFI groups. Participants in the FOI group performed fiberoptic intubation without the aid of any device, whereas those in the VAFI group used a video laryngoscope to obtain a better glottic view. The primary outcome was the time from the moment the tip of the flexible bronchoscope passed between the upper and lower incisors until the completion of tracheal intubation. RESULTS A total of 28 participants were enrolled in this study. There was no significant difference in the time until the completion of tracheal intubation between FOI and VAFI, with a median time of 55.0 seconds for FOI and 42.5 seconds for VAFI (P = 0.22). Secondary outcomes, including time until passing the vocal cord, the number of intubation attempts, and the first success rate, did not also illustrate the significant difference between the groups. CONCLUSION This study did not demonstrate the superiority of VAFI over conventional FOI in a high-fidelity pediatric simulator by medical providers with no experience in tracheal intubation.
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Affiliation(s)
- Hatsuo Isogai
- Department of Anaesthesiology, Aichi Children's Health and Medical Center, Obu, JPN
| | - Taiki Kojima
- Department of Anaesthesiology, Aichi Children's Health and Medical Center, Obu, JPN
- Division of Comprehensive Paediatric Medicine, Nagoya University Graduate School of Medicine, Nagoya, JPN
| | - Hiromi Kako
- Department of Anaesthesiology, Aichi Children's Health and Medical Center, Obu, JPN
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Garcia-Marcinkiewicz AG, Lee LK, Haydar B, Fiadjoe JE, Matava CT, Kovatsis PG, Peyton J, Stein ML, Park R, Taicher BM, Templeton TW. Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry. Br J Anaesth 2023:S0007-0912(23)00122-8. [PMID: 37076335 DOI: 10.1016/j.bja.2023.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. METHODS We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. RESULTS The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. CONCLUSIONS Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.
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Affiliation(s)
| | - Lisa K Lee
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Bishr Haydar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - John E Fiadjoe
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - James Peyton
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Mary L Stein
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Raymond Park
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Brad M Taicher
- Department of Anesthesiology, Duke Children's Hospital & Health Center, Durham, NC, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Asai T, Jagannathan N. Videolaryngoscopy Is Extremely Valuable, But Should It Be the Standard for Tracheal Intubation? Anesth Analg 2023; 136:679-682. [PMID: 36928153 DOI: 10.1213/ane.0000000000006313] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- Takashi Asai
- From the Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Narasimhan Jagannathan
- Phoenix Children's Hospital, Phoenix, Arizona
- University of Arizona School of Medicine, Phoenix, Arizona
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Bai W, Klumpner T, Zhao X, Mentz G, Green G, Riegger LQ, Malviya S, Brown SES. Difficult airway management in children with trisomy 18: a retrospective single-centre study of incidence, outcomes, and complications. Br J Anaesth 2023; 130:e471-e473. [PMID: 36966022 DOI: 10.1016/j.bja.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/27/2023] Open
Affiliation(s)
- Wenyu Bai
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Thomas Klumpner
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Xinyi Zhao
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Glenn Green
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lori Q Riegger
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shobha Malviya
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sydney E S Brown
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
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Videolaryngoscopy in neonates: A narrative review exploring the current state of the art. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
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Riva T, Engelhardt T, Basciani R, Bonfiglio R, Cools E, Fuchs A, Garcia-Marcinkiewicz AG, Greif R, Habre W, Huber M, Petre MA, von Ungern-Sternberg BS, Sommerfield D, Theiler L, Disma N. Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:101-111. [PMID: 36436541 DOI: 10.1016/s2352-4642(22)00313-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/14/2022] [Accepted: 10/14/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tracheal intubation in neonates and infants is a potentially life-saving procedure. Video laryngoscopy has been found to improve first-attempt tracheal intubation success and reduce complications compared with direct laryngoscopy in children younger than 12 months. Supplemental periprocedural oxygen might increase the likelihood of successful first-attempt intubation because of an increase in safe apnoea time. We tested the hypothesis that direct laryngoscopy is not inferior to video laryngoscopy when using standard blades and supplemental oxygen is provided. METHODS We did a non-inferiority, international, multicentre, single-blinded, randomised controlled trial, in which we randomly assigned neonates and infants aged up to 52 weeks postmenstrual age scheduled for elective tracheal intubation to either direct laryngoscopy or video laryngoscopy (1:1 ratio, randomly assigned using a secure online service) at seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. An expected difficult intubation was the main exclusion criteria. Parents and patients were masked to the assigned group of treatment. All infants received supplemental oxygen (1 L/Kg per min) during laryngoscopy until the correct tracheal tube position was confirmed. The primary outcome was the proportion of first-attempt tracheal intubation success, defined as appearance of end-tidal CO2 curve at the anaesthesia monitor, between the two groups in the modified intention-to-treat analysis. A 10% non-inferiority margin between direct laryngoscopy or video laryngoscopy was applied. The trial is registered with ClinicalTrials.gov (NCT04295902) and is now concluded. FINDINGS Of 599 patients assessed, 250 patients were included between Oct 26, 2020, and March 11, 2022. 244 patients were included in the final modified intention-to-treat analysis. The median postmenstrual age on the day of intubation was 44·0 weeks (IQR 41·0-48·0) in the direct laryngoscopy group and 46·0 weeks (42·0-49·0) in the video laryngoscopy group, 34 (28%) were female in the direct laryngoscopy group and 38 (31%) were female in the video laryngoscopy group. First-attempt tracheal intubation success rate with no desaturation was higher with video laryngoscopy (89·3% [95% CI 83·7 to 94·8]; n=108/121) compared with direct laryngoscopy (78·9% [71·6 to 86·1]; n=97/123), with an adjusted absolute risk difference of 9·5% (0·8 to 18·1; p=0·033). The incidence of adverse events between the two groups was similar (-2·5% [95% CI -9·6 to 4·6]; p=0·490). Post-anaesthesia complications occurred seven times in six patients with no difference between the groups. INTERPRETATION Video laryngoscopy with standard blades in combination with supplemental oxygen in neonates and infants might increase the success rate of first-attempt tracheal intubation, when compared with direct laryngoscopy with supplemental oxygen. The incidence of hypoxaemia increased with the number of attempts, but was similar between video laryngoscopy and direct laryngoscopy. Video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated. FUNDING Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, National Health and Medical Research Council.
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Affiliation(s)
- Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Reto Basciani
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Rachele Bonfiglio
- Unit for Research in Anaesthesia, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Evelien Cools
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery G Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria-Alexandra Petre
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, Australia; Perioperative Medicine Team, Telethon Kids Institute, Perth, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, Australia; Perioperative Medicine Team, Telethon Kids Institute, Perth, Australia
| | - Lorenz Theiler
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicola Disma
- Unit for Research in Anaesthesia, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy.
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Manley BJ, Hodgson KA. Addressing the subpar success rates of infant intubation. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:80-81. [PMID: 36436540 DOI: 10.1016/s2352-4642(22)00317-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Brett J Manley
- Newborn Research, The Royal Women's Hospital, Melbourne, VIC 3052, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Kate A Hodgson
- Newborn Research, The Royal Women's Hospital, Melbourne, VIC 3052, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
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Wang X, Xu T. Low vs high oxygen during neonatal anesthesia. Paediatr Anaesth 2023; 33:91-92. [PMID: 36288917 DOI: 10.1111/pan.14571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/03/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Xie Wang
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Ting Xu
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
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Lyra JC, Guinsburg R, de Almeida MFB, Variane GFT, Souza Rugolo LMSD. Use of laryngeal mask for neonatal resuscitation in Brazil: A national survey. Resusc Plus 2022; 13:100336. [PMID: 36582476 PMCID: PMC9792880 DOI: 10.1016/j.resplu.2022.100336] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/06/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Abstract
Background The International Liaison Committee on Resuscitation suggests using the laryngeal mask airway (LMA) as an alternative to the face mask for performing positive pressure ventilation (PPV) in the delivery room in newborns ≥34 weeks. Because not much is known about the health professionals' familiarity in using LMA in Brazil, this study aimed to describe the health professionals' knowledge and practice of using LMA, who provide neonatal care in the country. Methods An online questionnaire containing 29 questions was sent to multi-healthcare professionals from different regions in the country through email and social media groups (WhatsApp®, Instagram®, Facebook®, and LinkedIn®). The participants anonymously answered the questions regarding their knowledge and expertise in using LMA to ventilate newborns in the delivery room. Results We obtained 749 responses from all the regions in Brazil, with 80% from health professionals working in public hospitals. Most respondents were neonatologists (73%) having > 15 years of clinical practice. Among the respondents, 92% recognized the usefulness of LMA for performing PPV in newborns, 59% did not have specific training in LMA insertion, and only 8% reported that they have already used LMA in the delivery room. In 90% of the hospitals, no written protocol was available to use LMA; and in 68% of the hospitals, LMA was not available for immediate use. Conclusion This nationwide survey showed that most professionals recognize the usefulness of LMA. However, the device is scarcely available and underused in the routine of ventilatory assistance for newborns in delivery rooms in Brazil.
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Affiliation(s)
- João Cesar Lyra
- Department of Pediatrics, UNESP – Univ Estadual Paulista, Sao Paulo State, Brazil,Corresponding author at: Department of Pediatrics, UNESP – Univ Estadual Paulista, Sao Paulo State, Distrito de Rubiao Junior – Av. Prof, Mario Rubens Guimaraes Montenegro s/n; Botucatu, Sao Paulo 18618-687, Brazil.
| | - Ruth Guinsburg
- Division of Neonatal Medicine - Escola Paulista de Medicina - Universidade Federal de São Paulo, Brazil
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Saracoglu A, Saracoglu KT, Sorbello M, Kurdi R, Greif R. A view on pediatric airway management: a cross sectional survey study. Minerva Anestesiol 2022; 88:982-993. [PMID: 35833855 DOI: 10.23736/s0375-9393.22.16445-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
BACKGROUND This survey aimed to investigate routine practices and approaches of clinicians on pediatric airway in anesthesia and intensive care medicine. METHODS A 20-question multiple-choice questionnaire with the possibility to provide open text answers was developed and sent. The survey was sent to the members of European Airway Management Society via a web-based platform. Responses were analyzed thematically. Only the answers from one representative of the pediatric service of each hospital was included into the analysis. RESULTS Among the members, 143 physicians responded the survey, being anesthesiologists (83.2%), intensivists (11.9%), emergency medicine physicians (2.1%), and (2.8%) pain medicine practitioners. A straight blade was preferred by 115 participants (80.4%) in newborns, whereas in infants 86 (60.1%) indicated a curved blade and 55 (38.5%) a straight blade. Uncuffed tracheal tube were preferred by 115 participants (80.4%) in newborns, whereas 24 (16.8%) used cuffed tubes. Approximately 2/3 of the participants (89, 62.2%) reported not to use routinely a cuff manometer in their clinical practice, whereas 54 participants (37.8%) use it routinely in pediatric patients. Direct laryngoscopy for routine pediatric tracheal intubation was reported by 127 participants (88.8%), while 16 (11.2%) reported using videolaryngoscopes routinely. Interestingly, 39 (27.3%) had never performed neither videolaryngoscopy nor flexible bronchoscopy in children. These results were significantly less in hospitals with a dedicated pediatric anesthesiologist. CONCLUSIONS This survey on airway management in pediatric anesthesia revealed that the use of cuffed tubes and the routine monitoring of cuff pressure are rare. In addition, the rate of videolaryngoscopy or flexible optical intubation was low for expected difficult intubation. Our survey highlights the need for properly trained pediatric anesthesiologists working in-line with updated scientific evidence.
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Affiliation(s)
- Ayten Saracoglu
- Department of Anesthesiology and Intensive Care, Marmara University Medical School, Istanbul Turkey
| | - Kemal T Saracoglu
- Department of Anesthesiology and Intensive Care, Kartal Dr. Lutfi Kirdar City Hospital, Health Sciences University, Istanbul Turkey -
| | - Massimiliano Sorbello
- Department of Anesthesiology and Intensive Care, AOU Policlinico San Marco, Catania, Italy
| | - Raghad Kurdi
- Department of Anesthesiology and Intensive Care, Marmara University Medical School, Istanbul Turkey
| | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital Inselspital, Bern, Switzerland
- School of Medicine, Sigmund Freud University, Vienna, Austria
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Special considerations in the premature and ex-premature infant. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kalbande JV, Deotale KD, Singha SK, Karim HMR, Dubey R. A Rare Case of Giant Occipital Encephalocele With Thoracic Myelomeningocele: An Anesthetic Conundrum. Cureus 2022; 14:e29602. [PMID: 36321061 PMCID: PMC9599913 DOI: 10.7759/cureus.29602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/06/2022] Open
Abstract
Encephalocele and myelomeningocele are congenital defects in the cranium and spine with herniation of contents into an extracranial and extraspinal sac, respectively. The occurrence of encephalocele and myelomeningocele in the same patient has rarely been described in the literature. The anesthetic management of such cases is associated with multiple challenges, which include difficulty in securing the airway, prone positioning, blood loss, electrolyte imbalance, hypothermia, cardiorespiratory disturbances, and perioperative care. The main aims are, to prevent hemodynamic fluctuations and excessive pressure on the sac to avoid premature rupture and manage a possible difficult airway due to the head and neck mass. We report such a rare case to highlight and share our experiences faced during perioperative management of a giant vascular occipital encephalocele with impending rupture and thoracic myelomeningocele requiring surgical excision and repair. Previous similar case reports were also reviewed, and potential perioperative complications were discussed.
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Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol 2022; 42:1221-1227. [PMID: 35982243 DOI: 10.1038/s41372-022-01484-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between number of attempts and adverse events during neonatal intubation. STUDY DESIGN A retrospective study of prospectively collected data of intubations in the delivery room and NICU from the National Emergency Airway Registry for Neonates (NEAR4NEOS) in 17 academic centers from 1/2016 to 12/2019. We examined the association between tracheal intubation attempts [1, 2, and ≥3 (multiple attempts)] and clinical adverse outcomes (any tracheal intubation associated events (TIAE), severe TIAE, and severe oxygen desaturation). RESULTS Of 7708 intubations, 1474 (22%) required ≥3 attempts. Patient, provider, and practice factors were associated with higher TI attempts. Increasing intubation attempts was independently associated with a higher risk for TIAE. The adjusted odds ratio for TIAE and severe oxygen desaturation were significantly higher in TIs with 2 and ≥3 attempts than with one attempt. CONCLUSION The risk of adverse safety events during intubation increases with the number of intubation attempts.
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Kwon JH, Chung YJ, Her S, Jeong JS, Kim C, Min JJ. Comparison of two sizes of GlideScope® blades in tracheal intubation of infants: a randomised clinicaltrial ☆. Br J Anaesth 2022; 129:635-642. [PMID: 35999074 DOI: 10.1016/j.bja.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The appropriate size of GlideScope® blade for tracheal intubation in neonates and premature infants has not been established. We evaluated the impact of the size of the GlideScope® blade on the time taken for intubation in infants weighing 2.5-3.6 kg. METHODS Sixty infants weighing 2.5-3.6 kg were randomly assigned to use of the size 1 blade (n=30) or the size 2 blade (n=30). The primary outcome was the time taken to intubate. Components related to the laryngoscopic view which could affect the duration of the intubating process were also analysed. RESULTS The time required for tracheal intubation was shorter with the size 2 blade than with the size 1 blade (16 [14-20] s vs 22 [18-25] s, P=0.002; median difference=-5; 95% confidence interval, -7 to -2). The rate at which the tip of the tracheal tube was located at the centre of the laryngeal inlet was higher with the size 2 blade than with the size 1 blade (83% vs 40%, P<0.001). Correlation analysis indicated that the time required to find the tip of the tube was related to how far the lower border of the arytenoid cartilages was located from the mid-horizontal line of the monitor (r=0.28, P=0.033). CONCLUSION Use of the size 2 blade significantly reduced the time required to intubate the trachea, compared with the size 1 GlideScope® blade in infants. CLINICAL TRIAL REGISTRATION KCT 0003867.
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Affiliation(s)
- Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon Joo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sukyoung Her
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chungsu Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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"Sedation versus General Anesthesia For Tracheal Intubation In Children With Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry.". Anesthesiology 2022; 137:418-433. [PMID: 35950814 DOI: 10.1097/aln.0000000000004353] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of our study is to compare the first attempt success rate of tracheal intubation during sedated tracheal intubation vs. tracheal intubation under general anesthesia (GA). We hypothesized that sedated intubation would be associated with a lower first attempt success rate and more complications than general anesthesia. METHODS We used data from an international observational registry, Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. We compared the use of sedation versus general anesthesia for tracheal intubation. Our primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and non-severe and severe complications. We used propensity score matching with a matching ratio up to 1:15 to reduce bias due to measured confounders. RESULTS Between 2017 and 2020, 34 hospitals submitted 1839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation and 1764 patients received GA. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the GA group. The rate of first-attempt success of tracheal intubation was 28/58 (48.3%) in the sedation group and 250/522 (47.9%) in the GA-group (OR 1.06, 95% CI 0.60 - 1.87; p=0.846); The median number of intubations attempts was 2 [IQR 1, 3] in the sedation group and 2 [IQR 1, 2] in the GA group. The GA group had 6/522 (1.1%) intubation failures versus 0/58 in the sedation group. However, Sixteen of fifty-eight (27.6%) sedation cases had to be converted to GA for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low. CONCLUSION Sedation and GA had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to GA to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low.
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Walker SM, Engelhardt T, Ahmad N, Dobby N, Masip N, Brooks P, Hare A, Casey M, De Silva S, Krishnan P, Sogbodjor LA, Walker E, King S, Nicholson K, Quinney M, Stevens P, Blevin A, Giombini M, Goonasekera C, Adil S, Bew S, Bodlani C, Gilpin D, Jinks S, Malarkkan N, Miskovic A, Pad R, Barry JW, Abbott J, Armstrong J, Cooper N, Crate L, Emery J, James K, King H, Martin P, Catenacci SS, Bomont R, Smith P, Mele S, Verzelloni A, Dix P, Bell G, Gordeva E, McKee L, Ngan E, Scheffczik J, Tan LE, Worrall M, Cassar C, Goddard K, Barlow V, Oshan V, Shah K, Bell S, Daniels L, Gandhi M, Pachter D, Perry C, Robertson A, Scott C, Waring L, Barnes D, Childs S, Norman J, Sunderland R, Disma N, Veyckemans F, Virag K, Hansen TG, Becke K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W. Perioperative critical events and morbidity associated with anesthesia in early life: Subgroup analysis of United Kingdom participation in the NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective multicenter observational study. Paediatr Anaesth 2022; 32:801-814. [PMID: 35438209 PMCID: PMC9322016 DOI: 10.1111/pan.14457] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries. METHODS Subgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30-day morbidity and mortality between participating UK and nonUK centers. RESULTS Seventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, and 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25-60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co-morbidities or requiring preoperative intensive support. A higher proportion of UK than nonUK cases were graded as ASA-Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty-day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from nonUK participants. CONCLUSIONS Perioperative critical events and co-morbidities are common in neonates and young infants. Thirty-day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families.
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Affiliation(s)
- Suellen M. Walker
- Department of Paediatric AnaesthesiaGreat Ormond St Hospital NHS Foundation TrustLondonUK,Developmental NeurosciencesUCL GOS Institute of Child HealthLondonUK
| | - Thomas Engelhardt
- Department of AnaesthesiaMontreal Children's HospitalMontrealQCCanada
| | - Nargis Ahmad
- Department of Paediatric AnaesthesiaGreat Ormond St Hospital NHS Foundation TrustLondonUK
| | - Nadine Dobby
- Department of Paediatric AnaesthesiaGreat Ormond St Hospital NHS Foundation TrustLondonUK
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Robinson EJ, Lyne TC, Blaise BJ. Safety of general anaesthetics on the developing brain: are we there yet? BJA OPEN 2022; 2:100012. [PMID: 37588272 PMCID: PMC10430845 DOI: 10.1016/j.bjao.2022.100012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/11/2022] [Indexed: 08/18/2023]
Abstract
Thirty years ago, neurotoxicity induced by general anaesthetics in the developing brain of rodents was observed. In both laboratory-based and clinical studies, many conflicting results have been published over the years, with initial data confirming both histopathological and neurodevelopmental deleterious effects after exposure to general anaesthetics. In more recent years, animal studies using non-human primates and new human cohorts have identified some specific deleterious effects on neurocognition. A clearer pattern of neurotoxicity seems connected to exposure to repeated general anaesthesia. The biochemistry involved in this neurotoxicity has been explored, showing differential effects of anaesthetic drugs between the developing and developed brains. In this narrative review, we start with a comprehensive description of the initial concerning results that led to recommend that any non-essential surgery should be postponed after the age of 3 yr and that research into this subject should be stepped up. We then focus on the neurophysiology of the developing brain under general anaesthesia, explore the biochemistry of the observed neurotoxicity, before summarising the main scientific and clinical reports investigating this issue. We finally discuss the GAS trial, the importance of its results, and some potential limitations that should not undermine their clinical relevance. We finally suggest some key points that could be shared with parents, and a potential research path to investigate the biochemical effects of general anaesthesia, opening up perspectives to understand the neurocognitive effects of repetitive exposures, especially in at-risk children.
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Affiliation(s)
- Emily J. Robinson
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Tom C. Lyne
- Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, St. Thomas' Hospital, London, UK
| | - Benjamin J. Blaise
- Center for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, St. Thomas' Hospital, London, UK
- Department of Paediatric Anaesthetics, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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