Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis

Anesthetic Considerations for Pediatric Patients with Craniofacial Anomalies: An Overview of Key Elements

This article reviews the key elements of anesthesia care for patients presenting for craniofacial surgeries, including preoperative evaluation and preparation, intraoperative management, and pain management strategies.

Success rates of video vs. direct laryngoscopy for endotracheal intubation in anesthesiology residents: a study protocol for a randomized controlled trial (JuniorDoc-VL-Trial)

BACKGROUND

Tracheal intubation is a core skill in airway management for anesthesiologists as well as for other medical professionals involved in advanced airway procedures. Traditionally, tracheal intubation in hospitals has been performed using a Macintosh blade for direct laryngoscopy (DL). However, recent literature increasingly supports the potential benefits of routine video laryngoscopy (VL). The aim of this study was to assess whether primary training in hyperangulated VL improves the first-pass success rate of tracheal intubation among first-year anesthesiology residents, compared to conventional DL training, in the operating room.

METHODS

The JuniorDoc-VL Trial is a randomized, controlled, patient-blinded clinical trial of novice anesthesiology residents trained in DL and VL. Thirty residents will be randomly assigned to either the intervention group (VL group) or the control group (DL group) with a 1:1 allocation. The first-pass-success (FPS) rates (primary endpoint) and complication rates (secondary endpoint) will be compared between groups.

DISCUSSION

We hypothesize that the primary use of hyperangulated video laryngoscopy (VL) in the experimental group will increase first-pass-success rates among inexperienced residents and reduce complication rates associated with advanced airway management in a mixed patient population. This study may provide an opportunity to develop strategies that allow physicians not routinely involved in anesthesia to effectively learn and maintain their skills in tracheal intubation.

TRIAL REGISTRATION

ClinicalTrials.gov Registry (NCT06360328). Registered on 09.04.2024.

Availability and Practice Patterns of Videolaryngoscopy and Adaptation of Apneic Oxygenation in Pediatric Anesthesia: A Cross-Sectional Survey of Pediatric Anesthesiologists

BACKGROUND

Videolaryngoscopy (VL) and apneic oxygenation are highly recommended and increasingly used in pediatric anesthesia practice; yet, availability, use in recommended clinical settings (e.g., neonates, airway emergencies, and out-of-operating-room tracheal intubation), and the association of VL availability with how pediatric anesthesiologists define difficult intubation have not been explored.

METHOD

An electronic survey was distributed to the members of several international pediatric anesthesia societies to examine the availability and practice patterns of VL and to explore the criteria used to define a difficult tracheal intubation in children in the context of VL.

RESULTS

The response rate was 12.9%. VL was reported to be "most likely available" in main pediatric operating rooms and offsite locations 93% and 80.1% of the time, respectively. Fifty-seven percent of participants would select VL first when anticipating a difficult tracheal intubation; nearly 30% of respondents would choose direct laryngoscopy first and VL as a backup in this scenario. One-third of subjects would select VL as their first choice for nonoperating room (non-OR) emergency tracheal intubation and for premature or newborn infants, regardless of anticipated difficulty with intubation. Thirty percent of subjects reported using apneic oxygenation during difficult laryngoscopy. Institutional VL availability was not associated with how providers defined difficult tracheal intubation.

CONCLUSION

VL is highly available, but the adoption of VL and apneic oxygenation for managing difficult tracheal intubation was lower than expected, given recent recommendations by pediatric anesthesia societies. There was heterogeneity in how difficult intubation was defined, resulting in a possible patient safety risk.

Investigation of the effectiveness of preoperative intubation simulation using a custom-made simulator for pediatric patients with difficult airway: a pilot study

The purpose of this study is to investigate whether preoperative intubation simulation using custom-made simulator is useful during anesthesia induction for the children who have difficult airway. We included the children under 15 years of age who have difficult airway which had been already known. Prior to the scheduled surgery, CT imaging was performed and a 3D reconstruction of the face from the chest was performed. Then custom-made airway simulator was made. We tried to intubate custom-made simulator of patients preoperatively. We planned how to intubate the patient for anesthesia induction from the result of intubation simulation. The findings of direct laryngoscopy were compared with the findings during intubation. Three patients were included in this study. It took up to 3 weeks to create a simulator, which was difficult due to time constraints to accommodate emergency surgeries. Simulation findings correlated well with findings during anesthesia induction. There were no cases of severe hypotension or hypoxia during induction of anesthesia with the planned intubation method. In conclusion, preoperative intubation simulation using custom-made simulator may be useful for the patients who have difficult airway.

Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights From an International Airway Registry (PeDI)

BACKGROUND

Small case series have described awake supraglottic airway placement in infants with significant airway obstruction and difficult intubations. We conducted this study to determine outcomes when supraglottic airways were placed in awake children enrolled in the international Pediatric Difficult Intubation Registry including success of ventilation, success of tracheal intubation, and complications.

METHODS

We reviewed the Pediatric Difficult Intubation Registry to identify all cases of awake supraglottic airway placement before planned tracheal intubation from August 2012 to September 2023 with subsequent review of details of awake supraglottic airway placement in the medical record. We present descriptive statistics of patient demographics, ventilation and intubation outcomes, and complications.

RESULTS

A supraglottic airway was placed in an awake child in 95 of 8061 (1.2%) cases in the Pediatric Difficult Intubation Registry. Median age was 37 days (range 0-17.6 years) and median weight was 3.7 kg (1.6-46.7 kg). Sixteen (17%) cases were in patients older than 2 years and 7 (7%) were in adolescents. Adequate ventilation via a supraglottic airway was achieved in 81/95 (85%, 95% confidence interval [CI], 77%-93%) encounters. Inadequate (n = 13) or impossible (n = 1) ventilation occurred in 14/95 (15%). No complications were reported with supraglottic airway placement. For subsequent intubation, there was a 35% (33/95) first-attempt success rate and 99% (94/95) eventual success, with 1 patient awakened after failed attempts at tracheal intubation. Hypoxia occurred during the first intubation attempt in 9/95 (9%) encounters. The incidence of hypoxia was lower in encounters in which ventilation via the supraglottic airway was adequate (4/81, 5%) than in encounters in which ventilation via the supraglottic airway was inadequate or impossible (5/14, 36%).

CONCLUSIONS

Although infrequently attempted, awake placement of a supraglottic airway in children with difficult airways achieved adequate ventilation and provided a conduit for oxygenation and ventilation after induction of anesthesia across a spectrum of ages.

Airway management in pediatrics: improving safety

Airway management in children poses unique challenges due to the different anatomy, physiology, and pathophysiology across the pediatric age span. The recently published joint European Society of Anaesthesiology and Intensive Care-British Journal of Anaesthesia (ESAIC-BJA) neonatal and infant airway management guidelines provide recommendations and suggestions to support clinicians in deciding the best strategy. These guidelines represent a framework with the most recent and up-to-date evidence, from the initial assessment to the management of normal and difficult airways up to the extubation phase. However, such guidelines have intrinsic limitations due to the lack of supporting evidence in various fields of airway management. Pediatric institutions should adopt guidelines after careful internal review according to the local circumstances, including caseload, equipment and expertise. The current narrative review focused on providing references and practical tips on pediatric airway management, which is still not completely elucidated. Moreover, the authors put particular emphasis on the influence of human factors on the overall success of tracheal intubation, the incidence of complications, and the outcomes for patients.

Lidocaine vs. Mometasone Furoate Around the Pediatric Tracheal Tube Cuff: Hemodynamic Stress Response and Postoperative Airway Complications: A Prospective, Randomized, Controlled Study

Introduction: According to the results of the APRICOT study, airway and respiratory complications constitute 60% of all anesthesia-related complications and may be life-threatening. The primary aim of this study was to evaluate the effect of lidocaine and mometasone spray on the hemodynamic stress response during tracheal intubation and extubation in children. Our secondary aim was to determine its effect on the incidence of postoperative airway complications. Materials and Methods: Following Ethics Committee approval (No: KIIA 2018/489) and clinical trial registration (No: NCT04085744), patient recruitment was initiated only after obtaining parental consent. Children of ASA I-II aged 0 to 16 years and undergoing elective surgery were included. A total of 91 patients were randomly divided into 3 groups. Group M: Patients treated with a topical corticosteroid 0.05% mometasone furoate spray (n = 30). Group L: Patients sprayed with 10% lidocaine (n = 30). Control group: Patients treated with 0.9% normal saline applied around the cuff (n = 31). The systolic, diastolic, and mean blood pressures, heart rate, and SpO2 values were recorded before operation, after induction, before and after tracheal intubation, and before and after extubation. Patients were followed up for 24 h postoperatively. Results: A statistically significant decrease was found in the lidocaine group for diastolic and mean arterial pressures measured after tracheal intubation (p = 0.018 and p = 0.027, respectively). There was a significant decrease in heart rate values in Group L after extubation (p = 0.024). Cough was observed in 5 patients in the control group at the postoperative 12th hour, but not in the other groups (p = 0.009). The distribution of sore throat severity, dyspnea, and hoarseness and the incidence of early postoperative bronchospasm, recorded in all follow-up periods, decreased; however, it did not show a statistically significant difference. Conclusions: In conclusion, this study revealed that the topical application of lidocaine and mometasone around the tracheal tube cuff in children not only reduces postoperative cough but also, in the case of lidocaine, suppresses the hemodynamic stress response during both tracheal intubation and extubation.

Coaching inexperienced clinicians before a high stakes medical procedure: randomized clinical trial

OBJECTIVE

To assess whether training provided to an inexperienced clinician just before performing a high stakes procedure can improve procedural care quality, measuring the first attempt success rate of trainees performing infant orotracheal intubation.

DESIGN

Randomized clinical trial.

SETTING

Single center, quaternary children's hospital in Boston, MA, USA.

PARTICIPANTS

A non-crossover, prospective, parallel group, non-blinded, trial design was used. Volunteer trainees comprised pediatric anesthesia fellows, residents, and student registered nurse anesthetists from 10 regional training programs during their pediatric anesthesiology rotation. Trainees were block randomized by training roles. Inclusion criteria were trainees intubating infants aged ≤12 months with an American Society of Anesthesiology physical status classification of I-III. Exclusion criteria were trainees intubating infants with cyanotic congenital heart disease, known or suspected difficult or critical airways, pre-existing abnormal baseline oxygen saturation <96% on room air, endotracheal or tracheostomy tubes in situ, emergency cases, or covid-19 infection.

INTERVENTIONS

Trainee treatment group received preoperative just-in-time expert intubation coaching on a manikin within one hour of infant intubation; control group carried out standard practice (receiving unstructured intraoperative instruction by attending pediatric anesthesiologists).

MAIN OUTCOME MEASURES

Primary outcome was the first attempt success rate of intraoperative infant intubation. Modified intention-to-treat analysis used generalized estimating equations to account for multiple intubations per trainee participant. Secondary outcomes were complication rates, cognitive load of intubation, and competency metrics.

RESULTS

250 trainees were assessed for eligibility; 78 were excluded, 172 were randomized, and 153 were subsequently analyzed. Between 1 August 2020 and 30 April 2022, 153 trainees (83 control, 70 treatment) did 515 intubations (283 control, 232 treatment). In modified intention-to-treat analysis, first attempt success was 91.4% (212/232) in the trainee treatment group and 81.6% (231/283) in the control group (odds ratio 2.42 (95% confidence interval 1.45 to 4.04), P=0.001). Secondary outcomes favored the intervention, showing significance for decreased cognitive load and improved competency. Complications were lower for the intervention than for the control group but the difference was not significant.

CONCLUSIONS

Just-in-time training among inexperienced clinicians led to increased first attempt success of infant intubation. Integration of a just-in-time approach into airway management could improve patient safety, and these findings could help to improve high stakes procedures more broadly. Randomized evaluation in other settings is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04472195.

Urgent surgical exploration for neonatal torsion under spinal anesthesia

INTRODUCTION/BACKGROUND

The repeated or lengthy use of general anesthesia (GA) in children under three years old is cautioned against due to potential neurodevelopment effects. Spinal anesthesia (SA) has emerged as a safe and effective alternative for routine pediatric urologic procedures. In this study, we describe the use of SA in the urgent surgical treatment of neonatal testicular torsion.

OBJECTIVE

We aim to evaluate the safety and efficacy of SA for urgent scrotal exploration in neonates.

STUDY DESIGN

We retrospectively collected data on neonates younger than 30 days old undergoing SA for the indication of testicular torsion from May 2018 to June 2022. We recorded patient demographics, adjuvant medications use, and time points for start/stop of spinal injection, procedure, and operating room utilization.

RESULTS

Six neonates, with an average age of 1.9 days of life and average weight of 3.4 kg, underwent scrotal exploration for testicular torsion using SA. Four patients (67%) required orchiectomy of the nonviable torsed testicle, and all patients underwent orchiopexy of the unaffected testicle. Mean total operative time was 45.3 (SD 11.7) minutes, including Gomco circumcision in five patients. One patient received preoperative intranasal dexmedetomidine for sedation. Mean time for SA administration was 6.3 (SD 5.5) minutes, with a mean total time in the operating room of 77.3 (SD 9.8) minutes. There were no perioperative or postoperative complications.

DISCUSSION

We describe a single institution experience of surgical management of neonatal torsion under SA. In this case series, SA was safely utilized for all neonates involved without the need for conversion to GA or intravenous (IV) sedation.

CONCLUSION

The use of SA is safe and efficacious for urgent scrotal exploration for testicular torsion in neonates, even those under 48 h of age. More widespread utilization requires collaboration between pediatric urologists and experienced pediatric anesthesiologists trained in SA.

The predictive value of chest X-ray for the depth of tracheal intubation in infants

OBJECTIVE

To determine the predictive value of chest X-ray for the depth of tracheal intubation in infants.

METHODS

Basic data of 161 infants under 3 years old was collected. Tracheal length was measured on preoperative chest radiographs to guide intubation depth. Correlation analysis was performed to examine relationships between tracheal length, age, and body weight.

RESULTS

161 cases (male/female = 142/19, no significant difference in sex, p = 0.09) were included, aged from 1 month to 28 months, weight from 2.5 kg to 18.0 kg. The endotracheal intubation depth reached the standard rate was 100 %, with 0 cases of over-deep or over-shallow intubation. Correlation analysis showed that tracheal length was positively correlated with both age and body weight, with stronger correlations observed in infants aged 1-12 months (r = 0.751 for age, r = 0.672 for weight, p < 0.01) compared to those aged 13-28 months (r = 0.672 for age, r = 0.408 for weight, p < 0.01).

CONCLUSION

Direct measurement of tracheal length on routinely performed chest X-rays is simple, feasible and safe, and may be another choice for guiding the depth of tracheal intubation in children.

Effect of high-flow nasal and buccal oxygenation on safe apnea time in children with open mouth: A randomized controlled trial

BACKGROUND

High-flow nasal oxygenation is reported to prolong duration of apnea while maintaining adequate oxygen saturation with the mouth closed. Also, buccal oxygenation is known to have similar effects in obese adults. We compared the effect of these two methods on prolongation of acceptable apnea time in pediatric patients with their mouth open.

METHODS

Thirty-eight patients, aged 0-10 years were randomly allocated to either the high-flow nasal oxygenation group (n = 17) or the buccal oxygenation group (n = 21). After induction of anesthesia including neuromuscular blockade, manual ventilation was initiated until the expiratory oxygen concentration reached 90%. Subsequently, ventilation was paused, and the patient's head was extended, and mouth was opened. The HFNO group received 2 L·min-1·kg-1 of oxygen, and the BO group received 0.5 L·min-1·kg-1 of oxygen. We set a target apnea time according to previous literature. When the apnea time reached the target, we defined the case as "success" in prolongation of safe apnea time and resumed ventilation. When the pulse oximetry decreased to 92% before the target apnea time, it was recorded as "failure" and rescue ventilation was given.

RESULTS

The success rate of safe apnea prolongation was 100% in the high-flow nasal oxygenation group compared to 76% in the buccal oxygenation group (p = .04). Oxygen reserve index, end-tidal or transcutaneous carbon dioxide partial pressure, and pulse oximetry did not differ between groups.

CONCLUSION

High-flow nasal oxygenation is effective in maintaining appropriate arterial oxygen saturation during apnea even in children with their mouth open and is superior to buccal oxygenation. Buccal oxygenation may be a good alternative when high-flow nasal oxygenation is not available.

Endotracheal intubation using a spiral endotracheal tube effectively reduces total tube handling time in children aged one month to six years using a McGrathTM video laryngoscope: a prospective randomized trial

BACKGROUND

Airway management in children is challenging because of the smaller size, different proportions of anatomical structures compared to adults, and a higher risk of hypoxemia. Efforts to improve the efficiency of pediatric intubation can be made by manually twisting a spiral endotracheal tube (ETT) using a flexible stylet to manipulate its shape and angle.

METHODS

This controlled trial randomized fifty children aged one month to six years who underwent elective surgery under general anesthesia into two groups (spiral ETT [sETT] and no-stylet ETT/standard ETT). The sETT was formed by twisting the ETT using a handmade tool. The primary objective was to determine the effectiveness of the sETT compared to the standard ETT in reducing intubation time. Secondary objectives were ETT placement accuracy, first-attempt intubation success rate, and adverse effects.

RESULTS

The mean total tube handling time in the sETT group was significantly shorter compared to the no-stylet ETT group (sETT 16.8 ± 3.6 vs. standard ETT 18.8 ± 3.7 seconds; P = 0.049). sETT placement had a significantly greater central placement accuracy (odds ratio, 4.846; 95% confidence interval, 1.287-18.255; P = 0.015). However, first-attempt successful intubation rate (sETT 80% vs. standard ETT 64%, P = 0.208) and total intubation time (sETT: 46.5 ± 5.2 vs. standard ETT 48.4 ± 4.9 seconds; P = 0.205) were not significantly different. No adverse effects were observed for either ETT type.

CONCLUSIONS

Spiral ETT effectively reduces total tube handling time and improves ETT placement accuracy in children using video laryngoscopy.

Top 100 most-cited articles on pediatric anesthesia from 1990 to 2023

Pediatric anesthesia presents greater challenges than does adult anesthesia. This bibliometric analysis aimed to analyze the top 100 most cited articles to be better understand the hot spots and prospects in pediatric anesthesia. Articles and reviews related to pediatric anesthesia were retrieved from the Web of Science Core Collection from 1990 to 2023. A bibliometric analysis of the top 100 most cited articles was also performed using information such as topics, author names, countries, institutions, publication years, and journals. A total of 32 831 articles were identified, with a total of 32 230 citations for the top 100 articles. The peak period for pediatric anesthesia research was from 2005 to 2009. The USA has emerged as the most active country in pediatric anesthesia research. Major journals published included Anesthesia and Analgesia, Anesthesiology, and Pediatrics, underscoring their authority in the field. Clinical studies on the top 100 most cited articles have focused on different stages of the perioperative period, the use of different anesthetic agents, and adverse outcomes in pediatric patients. The current study conducted a bibliometric analysis of the top 100 most cited articles in the field of pediatric anesthesia. Such insights are valuable for identifying research hot spots, assessing academic impact and collaboration in pediatric anesthesia, and guiding future research directions.

Effects of avoidance versus use of neuromuscular blocking agents for facilitation of tracheal intubation in children and infants: a protocol for a systematic review, meta-analysis and trial sequential analysis

BACKGROUND

The European Society of Anesthesiology and Intensive Care recommends the use of neuromuscular blocking agents (NMBA) in adults, to facilitate tracheal intubation and reduce its associated complications. Children who undergo tracheal intubation may suffer some of the same complications, however, no consensus exists regarding the use of NMBA for tracheal intubation in the pediatric population. We will explore the existing evidence assessing the effects of avoidance versus the use of NMBA for the facilitation of tracheal intubation in children and infants.

METHODS

This protocol follows the preferred reporting items for systematic reviews and meta-analyses protocols recommendations. We will include all randomized controlled clinical trials assessing the effects of avoidance versus the use of NMBA for facilitation of tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy in pediatric participants (<18 years). Our primary outcome is incidence of difficult tracheal intubation. Secondary outcomes include incidence of serious adverse events, failed intubation, events of upper airway discomfort or injury, and difficult laryngoscopy. We will conduct a thorough database search to identify relevant trials, including CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science, CINAHL, and trial registries. Two review authors will independently handle the screening of literature and data extraction. Each trial will be evaluated for major sources of bias with the "classic risk of bias tool" used in the Cochrane Collaboration tool from 2011. We will use Review manager (RevMan) or R with the meta package to perform the meta-analysis. We will perform a trial sequential analysis on the meta-analysis of our primary outcome, providing an estimate of statistical reliability. Two review authors will independently assess the quality of the body of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. We will use GRADEpro software to conduct the GRADE assessments and to create "Summary of the findings" tables.

Predictors of paediatric difficult intubation according to the experience of a university hospital in a low- and middle-income country: A prospective observational study

BACKGROUND

Difficult airway management is one of the main challenges in paediatric anaesthesia, particularly in low- and middle-income countries.

AIMS

The aim of this study was to investigate the main predictors of difficult paediatric intubation.

METHODS

In this observational study, we included all children aged less than five years undergoing intra-abdominal surgery with endotracheal intubation. Patients were divided into two groups according to the incidence of difficult intubation. Then, we investigated predictors for difficult paediatric intubation.

RESULTS

We included 217 children, and difficult intubation was observed in 10% of them. Predictors were as follows: Mallampati III-IV class (adjusted odds ratio = 2.21; 95% confidence interval = 1.1-6.4), limited mouth opening (adjusted odds ratio = 2.4; 95% confidence interval = 1.8-3.5), facial dysmorphia (adjusted odds ratio = 2.6; 95% confidence interval = 1.32-7.4) and anaesthesia without muscle relaxant (adjusted odds ratio = 1.8; 95% confidence interval = 1.0-5.1) or without opioids during crash inductions (adjusted odds ratio = 1.7; 95% confidence interval = 1.01-4.8).

CONCLUSION

Facial dysmorphia and limited mouth opening were predictors of difficult intubation in children. Furthermore, it seems that Mallampati class and anaesthesia technique may also predict challenging intubation, which may guide us to change our perioperative practice.

Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features

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.

First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility

OBJECTIVE

It is not clear whether video laryngoscopy (VL) is associated with a higher first-pass success rate in pediatric patients with limited neck mobility when compared with direct laryngoscopy (DL). We sought to determine the association between the laryngoscopy method and first-pass success.

METHODS

In this retrospective cohort study, we examined intubation data extracted from 2 prospectively collected, multicenter, airway management safety databases (National Emergency Airway Registry and the National Emergency Airway Registry for children), obtained during the years 2013-2018 in the emergency department. Intubations were included if patients were aged younger than 18 and had limited neck mobility. We compared first-pass success rates for ED intubations that were performed using VL versus DL. We built a structural causal model to account for potential confounders such as age, disease category (medical or trauma condition), other difficult airway characteristics, use of sedatives/paralytics, and laryngoscopist training level. We also analyzed adverse events as a secondary outcome.

RESULTS

Of 34,239 intubations (19,071 in the National Emergency Airway Registry and 15,168 in the National Emergency Airway Registry for children), a total of 341 intubations (1.0%) met inclusion criteria; 168 were performed via VL and 173 were performed via DL. The median age of patients was 124 months (interquartile range, 48-204). There was no difference in first-pass success between VL and DL (79.8% vs 75.7%, P = 0.44). Video laryngoscopy was not associated with higher first-pass success (odds ratio, 1.11; 95% confidence interval 0.84-1.47, with DL as a comparator) when a structural causal model was used to account for confounders. There was no difference in the adverse events between VL and DL groups (13.7% vs 8.7%, P = 0.19).

CONCLUSION

In children with limited neck mobility receiving tracheal intubation in the ED, neither VL nor DL was associated with a higher first-pass success rate.

The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study

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.

Emergency front-of-neck access in pediatric anesthesia: A narrative review

BACKGROUND AND OBJECTIVES

Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life-threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front-of-neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front-of-neck access in children.

METHODS

A comprehensive literature was performed the use of emergency front-of-neck access (eFONA) in infants and children.

RESULTS

Eighty-six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported.

CONCLUSION

Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure.

Lessons learned from big data (APRICOT, NECTARINE, PeDI)

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.

A systematic review on safety and surgical and anesthetic risks of elective abdominal laparoscopic surgery in infants to guide laparoscopic ovarian tissue harvest for fertility preservation for infants facing gonadotoxic treatment

Background

Infertility is an important late effect of childhood cancer treatment. Ovarian tissue cryopreservation (OTC) is established as a safe procedure to preserve gonadal tissue in (pre)pubertal girls with cancer at high risk for infertility. However, it is unclear whether elective laparoscopic OTC can also be performed safely in infants <1 year with cancer. This systematic review aims to evaluate the reported risks in infants undergoing elective laparoscopy regarding mortality, and/or critical events (including resuscitation, circulatory, respiratory, neurotoxic, other) during and shortly after surgery.

Methods

This systematic review followed the Preferred reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting guideline. A systematic literature search in the databases Pubmed and EMbase was performed and updated on February 15th, 2023. Search terms included 'infants', 'intubation', 'laparoscopy', 'mortality', 'critical events', 'comorbidities' and their synonyms. Papers published in English since 2000 and describing at least 50 patients under the age of 1 year undergoing laparoscopic surgery were included. Articles were excluded when the majority of patients had congenital abnormalities. Quality of the studies was assessed using the QUIPS risk of bias tool.

Results

The Pubmed and Embase databases yielded a total of 12,401 unique articles, which after screening on title and abstract resulted in 471 articles to be selected for full text screening. Ten articles met the inclusion criteria for this systematic review, which included 1778 infants <1 years undergoing elective laparoscopic surgery. Mortality occurred once (death not surgery-related), resuscitation in none and critical events in 53/1778 of the procedures.

Conclusion

The results from this review illustrate that morbidity and mortality in infants without extensive comorbidities during and just after elective laparoscopic procedures seem limited, indicating that the advantages of performing elective laparoscopic OTC for infants with cancer at high risk of gonadal damage may outweigh the anesthetic and surgical risks of laparoscopic surgery in this age group.

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial

Importance

Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear.

Objective

To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.

Design, Setting, and Participants

Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.

Interventions

Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.

Main Outcomes and Measures

The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries.

Results

Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).

Conclusion and Relevance

In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT04701762.

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

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.

Association Between Age- and Sex-Specific Body Mass Index Percentile and Multiple Intubation Attempts: A Retrospective Cohort Analysis

BACKGROUND

Obesity distorts airways and slightly complicates intubations in adults, but whether obesity complicates pediatric intubations remains unclear. We, therefore, tested the primary hypothesis that increasing age- and sex-specific body mass index (BMI) percentile is associated with difficult intubation, defined as >1 intubation attempt.

METHODS

We conducted a retrospective analysis of pediatric patients between 2 and 18 years of age who had noncardiac surgery with oral endotracheal intubation. We assessed the association between BMI percentile and difficult intubation, defined as >1 intubation attempt, using a confounder-adjusted multivariable logistic regression model. Secondarily, we assessed whether the main association depended on preoperative substantial airway abnormality status or age group.

RESULTS

A total of 9339 patients were included in the analysis. Median [quartiles] age- and sex-specific BMI percentile was 70 [33, 93], and 492 (5.3%) patients had difficult intubation. There was no apparent association between age- and sex-specific BMI percentile and difficult intubation. The estimated odds ratio (OR) for having difficult intubation for a 10-unit increase in BMI percentile was 0.98 (95% confidence interval [CI], 0.95-1.005) and was consistent across the 3 age groups of early childhood, middle childhood, and early adolescence (interaction P = .53). Patients with preoperative substantial airway abnormalities had lower odds of difficult intubation per 10-unit increase in BMI percentile, with OR (95% CI) of 0.83 (0.70-0.98), P = .01.

CONCLUSIONS

Age- and sex-specific BMI percentile was not associated with difficult intubation in children between 2 and 18 years of age. As in adults, obesity in children does not much complicate intubation.

Delayed Sequence Intubation in Children, Why Not?

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.

Difficult intubation in syndromic versus nonsyndromic forms of micrognathia in children

BACKGROUND

We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first-attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first-attempt success rate.

METHODS

In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012-03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings.

RESULTS

Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First-attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p = .478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p = .959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: -0.7, 0.7; p = .999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: -0.5, 0.5; p = .999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p = .07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p = .185).

CONCLUSIONS

Presence of syndrome was not associated with lower first-attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy.

Organization and training for pediatric cardiac arrest in Danish hospitals: A nationwide cross-sectional study

Background

Improving survival from pediatric cardiac arrest requires a well-functioning system of care with appropriately trained healthcare providers and designated cardiac arrest teams. This study aimed to describe the current organization and training for pediatric cardiac arrest in Denmark.

Methods

 We performed a nationwide cross-sectional study. A questionnaire was distributed to all hospitals in Denmark with a pediatric department. The survey included questions about receiving patients with out-of-hospital cardiac arrest, protocols for extracorporeal life support, cardiac arrest team compositions, and training.

Results

We obtained responses from 17 of 19 hospitals with a pediatric department. In total, 76% of hospitals received patients with pediatric out-of-hospital cardiac arrest and 35% of hospitals had a protocol for extracorporeal life support. None of the hospitals had identical cardiac arrest team member compositions. The total number of team members ranged from 4-10, with a median of 8 members (IQR 7;9). In 84% of hospitals a specialized course in pediatric resuscitation was implemented and in 5% of hospitals, the specialized course was for the entire cardiac arrest team. Only few hospitals had training in laryngeal mask (6%) and intubation (29%) for pediatric cardiac arrest and none of them were trained in extracorporeal life support.

Conclusion

We found high variability in the composition of the pediatric cardiac arrest teams and training across the surveyed Danish hospitals. Many hospitals lack training in important pediatric resuscitation skills. Although many hospitals receive pediatric patients after out-of-hospital cardiac arrest, only few have protocols for transfer for extracorporeal life support.

Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model

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.

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time

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.

State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time

This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children's distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy.

Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis

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.

An analysis of a new rapid difficult airway response team in a vertically built children's hospital

BACKGROUND

Intrahospital transport is associated with adverse events. This challenge is amplified during airway management. Although difficult airway response teams have been described, little attention has been paid to patient transport during difficult airway management versus the alternative of managing patient airways without moving the patient. This is especially needed in a 22-floor vertical hospital.

HYPOTHESIS

Development of a rapid difficult airway response team and an associated difficult airway cart will allow for the ability to manage difficult airways in the patient's primary location.

METHODS

A retrospective chart review of all rapid difficult airway response activations from December 18, 2019 to December 31, 2021 was performed to determine the number of airways secured in the patient's primary location (primary outcome). Secondary outcomes included length of time until airway securement, airway device used, number of attempts, complications, use of front of neck access, and mortality.

RESULTS

There were 96 rapid difficult airway response activations in a 2-year period, with 18 activations deemed inappropriate. Of the 78 indicated rapid difficult airway response deployments, all activations resulted in a secure airway, and 76 (97.4%) of cases had an airway secured in the patient's primary location. The mean time to airway securement was 17.1 min (standard deviation 18.8 min). The most common methods of airway securement were direct laryngoscopy (42.3%, 33/78) and video laryngoscopy (29.5%, 23/78). The mean number of attempts by the rapid difficult airway response team was 1.4. There were no documented cases requiring front of neck access. The Cormack-Lehane airway grade at time of intubation was I-II in 83.3% (65/78) of activations. Rapid difficult airway response activation resulted in 16 cases of cardiac arrest and 4 patient deaths within 48 h.

CONCLUSIONS

A rapid difficult airway response team allows a large majority of patients' airways to be managed and secured in the patient's primary hospital location. Future directions include reducing time to airway securement and identifying factors associated with cardiac arrest.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

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).

Airway management in a two-year-old child with a tongue tumor using video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation (hybrid technique)

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.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Registries in pediatric anesthesiology: A brief history and a new way forward

Clinical registries are multicenter prospective observational datasets that have been used to examine current perioperative practices in pediatric anesthesia. These datasets have proven useful in quantifying the incidence of rare adverse outcomes. Data from registries can highlight associations between severe patient safety events and patient and procedure-related risk factors. Registries are an effective tool to delineate practices and outcomes in niche patient populations. They have been used to quantify uncommon complications of medications and procedures. Registries can be used to generate knowledge and to support quality improvement. Multicenter engagement can promote best clinical practices and foster professional networks. Registries are limited by their observational nature, which entails a lack of randomization as well as selection and treatment bias. The maintenance of registries over time can be challenging due to difficulties in modifying the included variables, collaborator fatigue, and continued outlay of resources to maintain the database and onboard new sites. These latter issues can lead to decreased data quality. In this article, we discuss key insights from several pediatric anesthesia registries and propose a new type of registry that addresses some shortcomings of the current paradigm.

From Brobdingnag to Lilliput: Gulliver's travels in airway management guidelines

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.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

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).

The role of WhatsApp™ in pediatric difficult airway management: A study from the PeDI Collaborative

BACKGROUND

Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI-C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI-C established a WhatsApp™ group to facilitate real-time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI-C members.

METHOD

Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI-C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI-C WhatsApp™ group.

RESULTS

5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case-sharing 78 (22.2%). The median number of responses to original stems was 9 [2-21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41-1.16]; p < .0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86-1.45]; p < .0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33-1.40], p < .0016), and clinical case-sharing (regression coefficient 1.2547, 95% CI [0.9401-1.5693] p < .0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice.

DISCUSSION

The PeDI-C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing.

Value of the Hyomental Distance Measured With Ultrasound in Forecasting Difficult Laryngoscopy in Newborns

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.

Atropine does not prevent hypoxemia and bradycardia in tracheal intubation in the pediatric emergency department: observational study

OBJECTIVE

The benefit of atropine in pediatric tracheal intubation is not well established. The objective of this study was to evaluate the effect of atropine on the incidence of hypoxemia and bradycardia during tracheal intubations in the pediatric emergency department.

METHODS

This is a single-center observational study in a tertiary pediatric emergency department. Data were collected on all tracheal intubations in patients from 31 days to incomplete 20 years old, performed between January 2016 and September 2020. Procedures were divided into two groups according to the use or not of atropine as a premedication during intubation. Records with missing data, patients with cardiorespiratory arrest, cyanotic congenital heart diseases, and those with chronic lung diseases with baseline hypoxemia were excluded. The primary outcome was hypoxemia (peripheral oxygen saturation ≤88%), while the secondary outcomes were bradycardia (decrease in heart rate >20% between the maximum and minimum values) and critical bradycardia (heart rate <60 bpm) during intubation procedure.

RESULTS

A total of 151 tracheal intubations were identified during the study period, of which 126 were eligible. Of those, 77% had complex, chronic underlying diseases. Atropine was administered to 43 (34.1%) patients and was associated with greater odds of hypoxemia in univariable analysis (OR: 2.62; 95%CI 1.15-6.16; p=0.027) but not in multivariable analysis (OR: 2.07; 95%CI 0.42-10.32; p=0.37). Critical bradycardia occurred in only three patients, being two in the atropine group (p=0.26). Bradycardia was analyzed in only 42 procedures. Atropine use was associated with higher odds of bradycardia in multivariable analysis (OR: 11.00; 95%CI 1.3-92.8; p=0.028).

CONCLUSIONS

Atropine as a premedication in tracheal intubation did not prevent the occurrence of hypoxemia or bradycardia during intubation procedures in pediatric emergency.

Global anaesthesia-related cardiac arrest rates in children: a systematic review and meta-analysis

BACKGROUND

Neonates and infants have a higher perioperative risk of cardiac arrest and mortality than adults. The Human Development Index (HDI) ranges from 0 to 1, representing the lowest and highest levels of development, respectively. The relation between anaesthesia safety and country HDI has been described previously. We examined the relationship among the anaesthesia-related cardiac arrest rate (ARCAR), country HDI, and time in a mixed paediatric patient population.

METHODS

Electronic databases were searched up to July 2022 for studies reporting 24-h postoperative ARCARs in children. ARCARs (per 10,000 anaesthetic procedures) were analysed in low-HDI (HDI<0.8) vs high-HDI countries (HDI≥0.8) and over time (pre-2001 vs 2001-22). The magnitude of these associations was studied using systematic review methods with meta-regression analysis and meta-analysis.

RESULTS

We included 38 studies with 5,493,489 anaesthetic procedures and 1001 anaesthesia-related cardiac arrests. ARCARs were inversely correlated with country HDI (P<0.0001) but were not correlated with time (P=0.82). ARCARs did not change between the periods in either high-HDI or low-HDI countries (P=0.71 and P=0.62, respectively), but were higher in low-HDI countries than in high-HDI countries (9.6 vs 2.0; P<0.0001) in 2001-22. ARCARs were higher in children aged <1 yr than in those ≥1 yr in high-HDI (10.69 vs 1.48; odds ratio [OR] 8.03, 95% confidence interval [CI] 5.96-10.81; P<0.0001) and low-HDI countries (36.02 vs 2.86; OR 7.32, 95% CI 3.48-15.39; P<0.0001) in 2001-22.

CONCLUSIONS

The high and alarming anaesthesia-related cardiac arrest rates among children younger than 1 yr of age in high-HDI and low-HDI countries, respectively, reflect an ongoing challenge for anaesthesiologists.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42021229919.