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Totonchi Z, Siamdoust SAS, Zaman B, Rokhtabnak F, Alavi SA. Comparison of laryngeal mask airway (LMA) insertion with and without muscle relaxant in pediatric anesthesia; a randomized clinical trial. Heliyon 2022; 8:e11504. [PMID: 36406720 PMCID: PMC9672355 DOI: 10.1016/j.heliyon.2022.e11504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/14/2022] [Accepted: 11/03/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction This study aimed to evaluate the effectiveness of using muscle relaxant on the ease of laryngeal mask airway (LMA) insertion and possibility of its related complications. Methods This double-blind, randomized clinical trial was performed on 60 children aged 1–4 years with ASA (American Society of Anesthesiology) I or II with upper limb injuries who were candidates for surgery. The patients were randomly allocated to the two groups receiving atracurium group as muscle relaxant (MR) or saline group (S). Results Regarding ease of placement, the LMA was inserted in 66.7% and 63.3% of patients straightforwardly in the MR and S groups, respectively. While it was performed with one maneuver in 23.3% and 26.7% of cases in the MR and S groups, respectively (p = 0.955). Moreover, LMA dislodgment in the two groups was 36.7% in the MR group and 20.0% in the S group without a meaningful difference (P = 0.152). The only complication observed in the two groups was laryngospasm, which occurred in 0.10% and 13.3% in the MR and S groups, respectively (p = 0.688). Conclusion In some pediatric anesthesia, the use of atracurium, as a muscle relaxant had no significant effect on capability of LMA insertion, maintaining airway patency, LMA seal pressure and oxygenation variations. Moreover, it did not have a preventive effect on the occurrence of complications such as laryngospasm.
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Kumar KR, Kalagara R, Subramaniam R, Singh S. C-MAC ® pediatric D-blade for intubation in a child with Hurler syndrome. J Anaesthesiol Clin Pharmacol 2022; 38:671-672. [PMID: 36778793 PMCID: PMC9912866 DOI: 10.4103/joacp.joacp_532_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/11/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Kanil R. Kumar
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Reshma Kalagara
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Swati Singh
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31-81. [PMID: 34762729 DOI: 10.1097/aln.0000000000004002] [Citation(s) in RCA: 364] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
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Dohrmann T, Muschol NM, Sehner S, Punke MA, Haas SA, Roeher K, Breyer S, Koehn AF, Ullrich K, Zöllner C, Petzoldt M. Airway management and perioperative adverse events in children with mucopolysaccharidoses and mucolipidoses: A retrospective cohort study. Paediatr Anaesth 2020; 30:181-190. [PMID: 31834659 DOI: 10.1111/pan.13787] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Children suffering from mucopolysaccharidoses (subtypes I, II, III, IV, VI, and VII) or mucolipidoses often require anesthesia, but are at high risk for perioperative adverse events. However, the impact of the disease subtype and the standard of care for airway management are still unclear. AIMS This study aimed to assess independent risk factors for perioperative adverse events in individuals with mucopolysaccharidoses/mucolipidoses and to analyze the interaction with the primary airway technique implemented. METHODS This retrospective study included individuals with mucopolysaccharidoses/mucolipidoses who underwent anesthesia at two high-volume centers from 2002 to 2016. The data were analyzed in a multivariate hierarchical model, accounting for repeated anesthesia procedures within the same patient and for multiple events within a single anesthesia. RESULTS Of 141 identified inpatients, 67 (63 mucopolysaccharidoses and 4 mucolipidoses) underwent 269 anesthesia procedures (study cases) for 353 surgical or diagnostic interventions. At least one perioperative adverse event occurred in 25.6% of the cases. The risk for perioperative adverse events was higher in mucopolysaccharidoses type I (OR 8.0 [1.5-42.7]; P = .014) or type II (OR 8.8 [1.3-58.6]; P = .025) than in type III. Fiberoptic intubation through a supraglottic airway was associated with the lowest risk for perioperative adverse events and lowest conversion rate. Direct laryngoscopy was associated with a significantly higher risk for airway management problems than indirect techniques (estimated event rates 47.8% vs 10.1%, OR 24.05 [5.20-111.24]; P < .001). The risk for respiratory adverse events was significantly higher for supraglottic airway (22.6%; OR 31.53 [2.79-355.88]; P = .001) and direct laryngoscopy (14.8%; OR 14.70 [1.32-163.44]; P = .029) than for fiberoptic intubation through a supraglottic airway (2.1%). CONCLUSIONS The disease subtype and primary airway technique were the most important independent risk factors for perioperative adverse events. Our findings indicate that in MPS/ML children with predicted difficult airway indirect techniques should be favored for the first tracheal intubation attempt.
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Affiliation(s)
- Thorsten Dohrmann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicole M Muschol
- Department of Pediatrics, Center for Obstetrics and Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark A Punke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian A Haas
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock, Rostock, Germany
| | - Katharina Roeher
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Breyer
- Department of Pediatric Orthopedics, AKK Altona Children's Hospital, Hamburg, Germany.,Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja F Koehn
- Department of Pediatrics, Center for Obstetrics and Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kurt Ullrich
- International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,International Center for Lysosomal Disorders (ICLD) and Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Walas W, Aleksandrowicz D, Kornacka M, Gaszyński T, Helwich E, Migdał M, Piotrowski A, Siejka G, Szczapa T, Bartkowska-Śniatkowska A, Halaba ZP. The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel. Scand J Trauma Resusc Emerg Med 2019; 27:87. [PMID: 31533787 PMCID: PMC6751579 DOI: 10.1186/s13049-019-0666-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022] Open
Abstract
Children form a specific group of patients, as there are significant differences between children and adults in both anatomy and physiology. Difficult airway may be unanticipated or anticipated. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient’s death. There are few paediatric difficult-airway guidelines available in the current literature, and some of these have significant limitations. This position paper, intended for unanticipated difficult airway, was elaborated by the panel of specialists representing the Polish Society of Anaesthesiology and Intensive Care as well as the Polish Neonatal Society. It covers both elective intubation and emergency situations in children in all age groups. An integral part of the paper is an algorithm. The paper describes in detail all stages of the algorithm considering some modification in specific age groups, i.e. neonates.
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Affiliation(s)
- Wojciech Walas
- Paediatric and Neonatal Intensive Care Unit, University Hospital in Opole, Opole, Poland
| | | | - Maria Kornacka
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Gaszyński
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland
| | - Ewa Helwich
- Clinic of Neonatology and Intensive Neonatal Care, Institute of Mother and Child Care, Warsaw, Poland
| | - Marek Migdał
- Paediatric Intensive Care Unit, Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Piotrowski
- Department of Anaesthesia and Intensive Care, Children's Memorial Health Institute, Warsaw, Poland
| | - Grażyna Siejka
- Department of Paediatric Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Alicja Bartkowska-Śniatkowska
- Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Zenon P Halaba
- Institute of Medicine, University of Opole, 48 Oleska Str, 45-052, Opole, Poland.
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Current Concepts in the Management of the Difficult Pediatric Airway. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00319-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ravi R, Mohan VK, Badhe AS, Mishra SK, Bidkar PU. Comparison of weight-based and pinna size-based selection of ProSeal laryngeal mask airway in paediatric population - A prospective exploratory trial. Indian J Anaesth 2019; 63:36-41. [PMID: 30745611 PMCID: PMC6341894 DOI: 10.4103/ija.ija_423_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Weight-based selection of ProSeal laryngeal mask airway (PLMA) size may be unreliable in some situations. The aim of this study was to compare the ventilation parameters using PLMA during controlled ventilation between weight-based size selection and pinna size-based selection in children. Methods A total of 204 patients were randomised to receive either pinna size-based (Group P) or weight-based (Group W) size selection of PLMA. We tested the hypothesis that pinna size-based selection of PLMA was better than weight-based selection of PLMA in paediatric patients during controlled ventilation under general anaesthesia in terms of oropharyngeal sealing pressure (the primary end-point) and Brimacombe score. Cuff pressure was maintained at 60 cm of H2O during the study. Secondary outcomes included the number of attempts for successful placement of PLMA, peak airway pressure, gastric tube placement, traumatic insertion, and complications were also compared. Parametric variables were analysed using unpaired t-test and categorical variables were analysed using Mann-Whitney and Chi-square test. Results In all, 200 patients were analysed. The mean oropharyngeal sealing pressure in Group P was 25.4 ± 3.5 cmH2O and 24.9 ± 3.8 cmH2O in Group W, (P = 0.34). There was no significant difference between the two groups in any of the secondary outcomes. There were no traumatic insertion or complications reported in both the groups. Conclusion Pinna-based size selection method can be used in PLMA placement in the paediatric population for positive pressure ventilation and it serves as an alternative method to weight-based selection.
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Affiliation(s)
- Ramya Ravi
- Department of Anesthesiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
| | - V K Mohan
- Department of Anesthesiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
| | - Ashok Shankar Badhe
- Department of Anesthesiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
| | - Sandeep Kumar Mishra
- Department of Anesthesiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
| | - Prasanna Udupi Bidkar
- Department of Anesthesiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
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Abstract
Background Patients suffering from mucopolysaccharidosis are among the most complex from the anesthesiological point of view, especially regarding the management of the airway. The evidence base for anesthesia management is often limited to case reports and small case series. Aims To identify useful information about experience with each subtype of mucopolysaccharidosis reported in the literature and propose a guide on the best options for airway management to the anesthesiologists who take care of these patients. Methods A query of the PubMed database specific for “anesthesia” and “mucopolysaccharidosis” and a further query specific for “mucopolysaccharidosis and difficult airway management” was conducted. We looked for those items that offered practical guidance to anesthesiological management. We did not exclude case reports, especially those that reported a specific technique, because of their practical suggestions. Results We identified 15 reviews, 17 retrospective case series, 5 prospective studies, and 28 case reports that focused on airway managements in anesthesia or had practical suggestions for preoperative evaluation and risk assessment. An accurate preoperative evaluation and the need for an experienced team are emphasized in all the reviewed articles and for each type of mucopolysaccharidosis. Many suggestions on how to plan the perioperative period have been highlighted. Insertion of a laryngeal mask airway generally improves ventilation and facilitates intubation with a fiberoptic bronchoscope. Furthermore, the videolaryngoscope is very useful in making intubation easier and facilitating bronchoscope passage. Conclusions Patients with mucopolysaccharidosis are at high risk for anesthesia-related complications and require a high level of attention. However, a multidisciplinary approach, combined with expertise in the use of new techniques and new devices for airway management, makes anesthesiological management safer. Further research with prospective studies would be useful. Electronic supplementary material The online version of this article (10.1186/s13052-018-0554-1) contains supplementary material, which is available to authorized users.
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Update on difficult airway management with a proposal of a simplified algorithm, unified and applied to our daily clinical practice. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hack HA, Walker RWM, Gardiner P. Anaesthetic Implications of the Changing Management of Patients with Mucopolysaccharidosis. Anaesth Intensive Care 2016; 44:660-668. [DOI: 10.1177/0310057x1604400612] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The mucopolysaccharidoses are a group of inherited metabolic disorders that are renowned for presenting clinical problems, particularly related to cardiac, airway, and skeletal abnormalities, in children during anaesthesia. The changing clinical management of the mucopolysaccharidoses can be described in three phases. An initial phase of accumulation and dissemination of knowledge about the management of this rare disease with a growing recognition that untreated Hurler syndrome and more severe forms of other phenotypes such as Hunter syndrome and Maroteaux–Lamy syndrome were associated with severe complications under anaesthesia. This was followed by a second phase reflecting the beneficial results of new treatments such as haemopoietic stem cell transplantation and enzyme replacement therapy. Early and successful transplantation has dramatically improved long-term outcome and reduced anaesthetic complications in children with Hurler syndrome. Enzyme replacement therapy is available for many forms of mucopolysaccharidosis. If commenced at an early age improvement in many organ systems may be observed with an improved quality of life. However, these current treatment regimens do not appear to improve neurocognitive dysfunction, or cardiac valvular or skeletal abnormalities. We are now entering a third phase where the partial benefits of these treatment regimens are resulting in an increasing number of older patients with partially corrected abnormalities, including difficult airways, presenting for ongoing treatment to a new and potentially unsuspecting group of clinicians. Major airway abnormalities may be encountered and current adult guidelines may need to be adapted. A multidisciplinary team approach involving paediatric and adult anaesthetists is recommended to optimise future management.
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Affiliation(s)
- H. A. Hack
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - R. W. M. Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK
| | - P. Gardiner
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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Kovatsis PG. Continuous ventilation during flexible fiberscopic-assisted intubation via supraglottic airways. Paediatr Anaesth 2016; 26:457-8. [PMID: 26956516 DOI: 10.1111/pan.12863] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Pete G Kovatsis
- Department of Anesthesiology, Boston Children's Hospital, Boston, MA, USA.
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12
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Abstract
Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.
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Affiliation(s)
- Rakhee Goyal
- Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
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Slinn SJ, Froom SR, Stacey MRW, Gildersleve CD. Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective? Paediatr Anaesth 2015; 25:20-6. [PMID: 25370686 DOI: 10.1111/pan.12564] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2014] [Indexed: 11/28/2022]
Abstract
Over the past two decades, a plethora of new airway devices has become available to the pediatric anesthetist. While all have the laudable intention of improving patient care and some have proven clinical benefits, these devices are often costly and at times claims of an advantage over current equipment and techniques are marginal. Supraglottic airway devices are used in the majority of pediatric anesthetics delivered in the U.K., and airway-viewing devices provide an alternative for routine intubation as well as an option in the management of the difficult airway. Yet hidden beneath the convenience of the former and the technology of the latter, the impact on basic airway skills with a facemask and the lack of opportunities to fine-tune the core skill of intubation represent an unrecognised and unquantifiable cost. A judgement on this value must be factored into the absolute purchase cost and any potential benefits to the quality of patient care, thus blurring any judgement on cost-effectiveness that we might have. An overall value on cost-effectiveness though not in strict monetary terms can then be ascribed. In this review, we evaluate the role of these devices in the care of the pediatric patient and attempt to balance the advantages they offer against the cost they incur, both financial and environmental, and in any quality improvement they might offer in clinical care.
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Affiliation(s)
- Simon J Slinn
- Department of Anaesthetics and Intensive Care Medicine, University Hospital of Wales, Cardiff, UK
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Marín PCE, Engelhardt T. Algorithm for difficult airway management in pediatrics. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Kuş A, Berk D, Gürkan Y, Solak M, Toker K. Management of Difficult Airway in a Failed Intubation with Videolaryngoscopy in an Infant Patient. Turk J Anaesthesiol Reanim 2014; 42:214-6. [PMID: 27366421 DOI: 10.5152/tjar.2014.65365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 07/01/2013] [Indexed: 11/22/2022] Open
Abstract
The videolaryngoscope is a useful alternative airway device for anaesthesia management of difficult airways. However videolaryngoscope intubation may fail due to lack of experience, incorrect application, inappropriate stylet, prior traumatic attempts, restricted cervical movement and limited oropharyngeal airspace. Using a stylet and correctly shaped endotracheal tube is important to facilitate tracheal intubation with the videolaryngoscope, especially in paediatric patients. However, anatomical difficulty in the placement of the laryngoscope blade, association with facial deformities such as micrognathia, having a short neck, cleft palate and being younger than 1 year increase the likelihood of a difficult airway. In this report, we present our approach to difficult airway management in a failed intubation with a videolaryngoscope in an infant undergoing cleft palate surgery.
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Affiliation(s)
- Alparslan Kuş
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Derya Berk
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Yavuz Gürkan
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Mine Solak
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Kamil Toker
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Sheeran PW, Walsh BK, Finley AM, Martin AK, Brenski AC. Management of difficult airway patients and the use of a difficult airway registry at a tertiary care pediatric hospital. Paediatr Anaesth 2014; 24:819-24. [PMID: 24471869 DOI: 10.1111/pan.12356] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Appropriate recognition and management of the pediatric difficult airway is essential. Two patient deaths in a 2-year period involving children with a known difficult airway led to the formation of the institution's multidisciplinary Difficult Airway Committee. METHODS Patients with a suspected difficult airway or a known difficult airway are entered into a registry of difficult airway patients. A note describing the airway and any experiences at airway manipulation is entered as part of a difficult airway note in the patient's electronic medical record as soon as the patient is recognized as having a difficult airway. A call system has been developed to mobilize expert emergency airway assistance for these patients. Multiple additional methods are employed to ensure that all hospital personnel are aware that these patients are difficult to intubate. RESULTS Since inception almost 6 years ago, 164 patients (mean age 9.2 years) have been enrolled in the difficult airway registry. Eighty-seven patients (53%) had one of 28 identified syndromes or diagnoses. The most common reasons for airway obstruction were mandibular hypoplasia/micrognathia, decreased neck extension, and limited temporomandibular joint mobility. One hundred sixty-one patients (98%) in the registry were predicted by history or physical to have a difficult airway. The mortality of registry patients was 9.8% (n = 16) and was most commonly due to co-existing diseases. During the time period reviewed, there was one in-hospital death of a known difficult airway patient, in which expert airway assistance was not obtained in a timely fashion. CONCLUSION The institution's difficult airway registry identifies patients with a suspected or known difficult airway. The presence of a difficult airway in children can usually be predicted based on history and physical examination by anesthesiologists and otolaryngologists. Providers without advanced airway skills, however, may not appreciate that an airway is difficult to intubate until multiple attempts have failed. Both redundant notification methods and a call system optimize medical care of these fragile patients.
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Affiliation(s)
- Paul W Sheeran
- Division of Pediatric Anesthesia, Department of Anesthesia, The University of Missouri Kansas City Medical Center, Kansas City, MO, USA; Division of Critical care, Department of Pediatrics, The University of Missouri Kansas City Medical Center, Kansas City, MO, USA
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19
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Abstract
Securing an airway is a vital task for the anesthesiologist. The pediatric patients have significant anatomical and physiological differences compared with adults, which impact on the techniques and tools that the anesthesiologist might choose to provide safe and effective control of the airway. Furthermore, there are a number of pathological processes, typically seen in the pediatric population, which present unique anatomical or functional difficulties in airway management. The presence of one of these syndromes or conditions can predict a "difficult airway." Many instruments and devices are currently available which have been designed to aid in airway management. Some of these have been adapted from adult designs, but in many cases require alterations in technique to account for the anatomical and physiological differences of the pediatric patient. This review focuses on assessment and management of pediatric airway and highlights the unique challenges encountered in children.
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Affiliation(s)
- Jeff Harless
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ramesh Ramaiah
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sanjay M Bhananker
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Elective use of supraglottic airway devices for primary airway management in children with difficult airways †. Br J Anaesth 2014; 112:742-8. [DOI: 10.1093/bja/aet411] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Algorithm for difficult airway management in pediatrics☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1097/01819236-201442040-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 2013; 60:1089-118. [PMID: 24132407 PMCID: PMC3825644 DOI: 10.1007/s12630-013-0019-3] [Citation(s) in RCA: 222] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 08/13/2013] [Indexed: 12/14/2022] Open
Abstract
Background Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.
Methods Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. Conclusions The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.
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Gosavi KS, Prashantha M, Kondwilkar BD, Dhende NP. Anaesthesia management in foetus-ex-fetu. Indian J Anaesth 2013; 57:195-7. [PMID: 23825824 PMCID: PMC3696272 DOI: 10.4103/0019-5049.111860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kundan Sandugir Gosavi
- Department of Anaesthesia and Critical Care, Grant Govt. Medical College, Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
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Barch B, Rastatter J, Jagannathan N. Difficult pediatric airway management using the intubating laryngeal airway. Int J Pediatr Otorhinolaryngol 2012; 76:1579-82. [PMID: 22889575 DOI: 10.1016/j.ijporl.2012.07.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 07/08/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the intubating laryngeal airway (ILA) in providing safe endotracheal intubation in pediatric patients with difficult airway; to describe a method for using flexible fiberoptic bronchoscopy with the ILA for evaluating the pediatric airway. METHODS Case series with chart review of the medical records of patients who had the ILA and fiberoptic intubation used to secure the airway at a tertiary pediatric hospital from January 2009 to January 2011. We documented the circumstances necessitating airway management, ILA success, airway evaluation findings, and medical conditions contributing to difficult airway. RESULTS Fifty patients met criteria for review. The median age was 59.8 months (0.3-244.1), and the median weight was 19.0 kg (2.6-86). Four cases (8%) were unanticipated difficult airways and 46 (92%) were anticipated difficult airways. Nine (18%) of the 50 procedures were performed emergently. Comorbid conditions included craniofacial syndromes (n=36), cervical spine instability/immobility (n=9), and airway hemorrhage (n=3). 48 (96%) patients were fiberoptically intubated on first attempt through the ILA. In 2 patients, fiberoptic intubation required a second attempt. The overall success rate using the ILA and fiberoptic intubation to secure the airway was 100%. CONCLUSION ILA and fiberoptic-guided tracheal intubation is a safe and effective method for securing the airway in pediatric patients with difficult airway and can be a useful alternative to direct laryngoscopy when laryngeal exposure is suboptimal.
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Affiliation(s)
- Bennett Barch
- Department of Otolaryngology - University of Illinois Hospital, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW Difficulties in pediatric airway management are common and continue to result in significant morbidity and mortality. This review reports on current concepts in approaching a child with a difficult airway. RECENT FINDINGS Routine airway management in healthy children with normal airways is simple in experienced hands. Mask ventilation (oxygenation) is always possible and tracheal intubation normally simple. However, transient hypoxia is common in these children usually due to unexpected anatomical and functional airway problems or failure to ventilate during rapid sequence induction. Anatomical airway problems (upper airway collapse and adenoid hypertrophy) and functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions. Children with an 'impaired' normal (foreign body, allergy, and inflammation) or an expected difficult (scars, tumors, and congenital) airway require careful planning and expertise. Training in the recognition and management of these different situations as well as a suitably equipped anesthesia workstation and trained personnel are essential. SUMMARY The healthy child with an unexpected airway problem requires clear strategies. The 'impaired' normal pediatric airway may be handled by anesthetists experienced with children, whereas the expected difficult pediatric airway requires dedicated pediatric anesthesia specialist care and should only be managed in specialized centers.
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Kirkpatrick K, Ellwood J, Walker RWM. Mucopolysaccharidosis type I (Hurler syndrome) and anesthesia: the impact of bone marrow transplantation, enzyme replacement therapy, and fiberoptic intubation on airway management. Paediatr Anaesth 2012; 22:745-51. [PMID: 22672476 DOI: 10.1111/j.1460-9592.2012.03897.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To assess the effect of bone marrow transplantation (BMT), enzyme replacement therapy (ERT), and a fiberoptic endotracheal intubation technique in patients with mucopolysaccharidosis type I (MPS I, Hurler syndrome). BACKGROUND The mucopolysaccharidoses are inherited metabolic conditions with a well-documented association with difficult airway management. We present the largest series to date of patients with Hurler syndrome (MPS I) and look at the impact of new treatments, such as BMT and ERT, on anesthesia and airway management. METHODS/MATERIALS We carried out a retrospective chart review of patients with MPSI undergoing anesthesia over 9 years at the Royal Manchester Children's Hospital. Data were collected on incidence of difficult and failed intubation and airway difficulties under anesthesia. RESULTS There were 39 patients identified, of which 20 had the attenuated form of MPS I and received ERT, 18 were treated by BMT and one patient received neither treatment. These patients had a total of 114 general anesthetics for 141 procedures. The incidence of airway complications overall is lower than previously reported at 31%. Patients with the attenuated form of the disease on ERT still have a high incidence of airway problems at 57% and a failed intubation rate of 3%. BMT patients on the other hand have a much lower incidence of airway complications at 14%, and there were no failed intubations in this group. CONCLUSIONS Managing the MPS1 patient continues to be a challenge but with treatment and newer forms of airway management it is improving.
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Abstract
CONTEXT Airway management in children suffering from mucopolysaccharidosis 1 (Hurler syndrome) remains challenging despite advances in both treatment and airway management techniques. OBJECTIVES Forty-one anaesthetic charts following ten children over a 6-year period (2004-2010) were reviewed with emphasis on airway problems. RESULTS All children had early stem cell transplantation at the age of 2 years or earlier. Mean (SD) age was 5 (4.3) years. Mask ventilation was difficult in five of 41 (12%) anaesthetics or in three of ten children. There were 29 intubations. Direct laryngoscopy was described as difficult (Cormack and Lehane ≥3) on 11 occasions in five of ten children. There were three of 26 (12%) failed intubations with direct laryngoscopy. These situations were resolved by a fibre-optic procedure, by laryngeal mask airway (LMA) insertion or by use of a videolaryngoscope. A laryngeal mask airway was used 11 times to avoid invasive airway management and once when direct laryngoscopy was impossible. CONCLUSION The airway management of children with mucopolysaccharidosis 1 remains critical, despite advances in both treatment and airway management techniques. Problems did not seem to increase as children grew older. We assume that technical improvements such as standardised use of the laryngeal mask airway or attached tube channel videolaryngoscopes as well as a stem cell transplantation treatment of the disease helped the management of older children with mucopolysaccharidosis 1.
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Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: a brief review. Can J Anaesth 2012; 59:704-15. [PMID: 22653838 DOI: 10.1007/s12630-012-9714-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 04/12/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE This article is a narrative review regarding the usage and effectiveness of introducers or catheters to facilitate tracheal intubation through a supraglottic airway (SGA) as an alternative intubation technique in normal and difficult airway management. SOURCES Relevant articles were obtained through Medline (1948-July 2011). The articles were subsequently cross-referenced for additional literature, and only articles published in English were included. PRINCIPAL FINDINGS In this review, we consider 32 reports using the LMA Classic™, LMA Unique™, LMA ProSeal™, LMA Supreme™, AuraOnce™, and i-gel™ as SGA conduits for intubation. In 13 articles, the use of an Aintree Intubation Catheter was described as an intubation introducer and resulted in high success rates in both elective and emergent situations. Eight studies used a guidewire exchange catheter technique. Although blind intubation using a guidewire resulted in a high failure rate, these studies found that using a bronchoscope improved successful intubation. Ten studies showed that insertion of a gum elastic bougie with a bronchoscope as an intubation introducer has high success rates compared with blind bougie insertion. One article described the use of a small endotracheal tube as an intermediary for tracheal intubation. CONCLUSIONS In failed intubation scenarios, supraglottic airways, such as the LMA Classic™ or LMA ProSeal™ can serve as a conduit for tracheal intubation. A number of techniques using introducers or catheters can facilitate the insertion of an adequately sized endotracheal tube, particularly guided by a bronchoscope. Usage of introducers or catheters through a supraglottic airway may be a useful alternative intubation technique in difficult airway management.
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Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia 2011; 66 Suppl 2:45-56. [DOI: 10.1111/j.1365-2044.2011.06934.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Scarpa M, Almássy Z, Beck M, Bodamer O, Bruce IA, De Meirleir L, Guffon N, Guillén-Navarro E, Hensman P, Jones S, Kamin W, Kampmann C, Lampe C, Lavery CA, Teles EL, Link B, Lund AM, Malm G, Pitz S, Rothera M, Stewart C, Tylki-Szymańska A, van der Ploeg A, Walker R, Zeman J, Wraith JE. Mucopolysaccharidosis type II: European recommendations for the diagnosis and multidisciplinary management of a rare disease. Orphanet J Rare Dis 2011; 6:72. [PMID: 22059643 PMCID: PMC3223498 DOI: 10.1186/1750-1172-6-72] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 11/07/2011] [Indexed: 01/09/2023] Open
Abstract
Mucopolysaccharidosis type II (MPS II) is a rare, life-limiting, X-linked recessive disease characterised by deficiency of the lysosomal enzyme iduronate-2-sulfatase. Consequent accumulation of glycosaminoglycans leads to pathological changes in multiple body systems. Age at onset, signs and symptoms, and disease progression are heterogeneous, and patients may present with many different manifestations to a wide range of specialists. Expertise in diagnosing and managing MPS II varies widely between countries, and substantial delays between disease onset and diagnosis can occur. In recent years, disease-specific treatments such as enzyme replacement therapy and stem cell transplantation have helped to address the underlying enzyme deficiency in patients with MPS II. However, the multisystem nature of this disorder and the irreversibility of some manifestations mean that most patients require substantial medical support from many different specialists, even if they are receiving treatment. This article presents an overview of how to recognise, diagnose, and care for patients with MPS II. Particular focus is given to the multidisciplinary nature of patient management, which requires input from paediatricians, specialist nurses, otorhinolaryngologists, orthopaedic surgeons, ophthalmologists, cardiologists, pneumologists, anaesthesiologists, neurologists, physiotherapists, occupational therapists, speech therapists, psychologists, social workers, homecare companies and patient societies. Take-home message Expertise in recognising and treating patients with MPS II varies widely between countries. This article presents pan-European recommendations for the diagnosis and management of this life-limiting disease.
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Jagannathan N, Kho MF, Kozlowski RJ, Sohn LE, Siddiqui A, Wong DT. Retrospective audit of the air-Q intubating laryngeal airway as a conduit for tracheal intubation in pediatric patients with a difficult airway. Paediatr Anaesth 2011; 21:422-7. [PMID: 21175955 DOI: 10.1111/j.1460-9592.2010.03494.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the efficacy of the ILA as a conduit for tracheal intubation in pediatric patients with a difficult airway. AIM The primary goals of this retrospective audit were to assess the clinical performance of the ILA in pediatric patients with a difficult airway, expand on our initial favorable experience with this device, and collect pilot data for future prospective and comparison studies. METHODS The charts of patients with a difficult airway in whom the ILA was used during a period of 1 year in a freestanding pediatric institution were reviewed following a practice change in the authors' institution favoring the ILA over the laryngeal mask airway as a conduit for tracheal intubation. RESULTS Thirty-four pediatric patients had an ILA placed during the course of their airway management. Eight of the 34 patients in this cohort required emergent airway management. The median age was 47.1 (0.3-202.2) months and the median weight was 16.3 (3.9-86.0) kilograms. Three of the cases were unanticipated difficult airways and the remaining were anticipated difficult airways as a result of craniofacial syndromes (n = 21), cervical spine instability or immobility (n = 7), or airway hemorrhage (n = 3). Thirty-three of the 34 patients (97%) were intubated on the first attempt through the ILA, with the aid of a fiberoptic bronchoscope (n = 25), a Shikani Optical Stylet (n = 7), or blindly (n = 2). In one patient, blind tracheal intubation required a second attempt for successful intubation, making the overall success rate 100%. Oxygen desaturation was noted in 6 of the 34 cases. CONCLUSIONS In a series of pediatric patients with difficult airways, the ILA was successfully used as a conduit for tracheal intubation in all patients. Visualization techniques may offer a greater degree of success in intubations through the ILA due to the potential for epiglottic down-folding in children.
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Affiliation(s)
- Narasimhan Jagannathan
- Department of Pediatric Anesthesiology, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60614, USA.
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Morley R, Walker R. Not all laryngeal masks are the same for difficult airway work. Paediatr Anaesth 2011; 21:169. [PMID: 21210886 DOI: 10.1111/j.1460-9592.2010.03481.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nagaraja RG, Wilson M, Wilson G, Marciniak B, Engelhardt T. The anatomic relationship between the internal jugular vein and the carotid artery in children after laryngeal mask insertion. An ultrasonographic study. Paediatr Anaesth 2011; 21:62-4. [PMID: 21155928 DOI: 10.1111/j.1460-9592.2010.03459.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Central venous cannulation, although challenging in children and prone to complications, is frequently required for total parenteral nutrition and infusion of drugs. AIM The aim of this study was to determine the anatomic relationship between the internal jugular vein (IJV) and carotid artery (CA) before, and after, insertion of laryngeal mask airway (LMA) in children using ultrasound. METHODS Patients aged 2-16 were recruited to this prospective study and divided into three groups of 20 patients each: group 1: LMA size 2, group 2: LMA size 2½, and group 3: LMA size 3. Prior to, and following, LMA insertion, the position and depth of the vessels, and time to locate them were recorded. All measurements were taken at the level of the cricoid cartilage in a neutral head position in the spontaneously breathing patient during expiration. The IJV position in relation to the CA was noticed as anterior (A), anterolateral (AL), lateral (L), or medial (M). RESULTS The position of the IJV was found to be in the anterolateral (AL) or anterior (A) position to the CA in the majority of cases. The anatomic relationship changed in 10/120 (8.3%) following insertion of the LMA. The mean depth was 0.80 (± 0.15) cm for the right IJV before LMA insertion and 0.84 (± 0.17) cm after insertion. Similar measurements were taken on the left side [0.81 (± 0.14) cm and 0.83 (± 0.18) cm]. The diameter as well as the depth of the IJV increased with the age and weight of the patient. CONCLUSIONS This study demonstrates that the IJV is anterior or anterolateral to the artery in the majority of cases and that the anatomic relationship may change following the insertion of the LMA. It supports the need for using ultrasound-guided techniques for IJV cannulation following LMA insertion in spontaneously breathing children.
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Affiliation(s)
- Ravi G Nagaraja
- Royal Aberdeen Children's Hospital, Foresterhill, Aberdeen, UK.
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Abstract
The incidence of unanticipated difficult or failed airway in otherwise healthy children is rare, and routine airway management in pediatric patients is easy in experienced hands. However, difficulties with airway management in healthy children are not infrequent in nonpediatric anesthetists and are a main reason for pediatric anesthesia-related morbidity and mortality. Clear concepts and strategies are, therefore, required to maintain oxygenation and ventilation in children. Several complicated algorithms for the management of the unanticipated difficult adult and pediatric airway have been proposed, but a simple structured algorithm for the pediatric patient with unanticipated difficult airway is missing. This paper proposes a simple step-wise algorithm for the unexpected difficult pediatric airway based on an adult Difficult Airway Society (DAS) protocol, discusses the role of recently introduced airway devices, and suggests a content of a pediatric airway trolley. It is intended as an easy to memorize and a practical guide for the anesthetist only occasionally involved in pediatric anesthesia care as well as a call to stimulate discussion about the management of the unanticipated difficult pediatric airway.
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Affiliation(s)
- Markus Weiss
- Department of Anaesthesia, University Children's Hospital, Steinwiessstrasse 75, Zurich, Switzerland.
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Weiss M, Mauch J, Becke K, Schmidt J, Jöhr M. Fiberoptisch unterstützte endotracheale Intubation durch die Larynxmaske im Kindesalter. Anaesthesist 2009; 58:716-21. [DOI: 10.1007/s00101-009-1573-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
This article looks at the current techniques and equipment recommended for the management of the difficult intubation scenario in pediatric practice. We discuss the general considerations including preoperative preparation, the preferred anesthetic technique and the use of both rigid laryngoscopic and fiberoptic techniques for intubation. The unanticipated scenario is also discussed.
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Affiliation(s)
- Robert W M Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Pendlebury, Manchester.
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Abstract
In 1988, when the Laryngeal Mask Airway-Classic (Intavent Orthofix, Maidenhead, UK), was introduced there were only two choices of airway management: tracheal tube or facemask. The supraglottic airway, as we now understand the term, did not exist. Yet, 20 years later, we are faced with an ever increasing choice of supraglottic airway devices (SAD). For many SADs, with the exception of the LMA-Classic and LMA-Proseal (Intavent Orthofix, Maidenhead, UK), there is a lack of high quality data of efficacy. The best evidence requires a randomized controlled trial comparing a new device against an established alternative, properly powered to detect clinically relevant differences in clinically important outcomes. Such studies in children are very rare. Safety data is even harder to establish particularly for rare events such as aspiration. Therefore, most safety data comes from extended use rather than high quality evidence which inevitably biases against newer devices. For reason of these factors, claims of efficacy and particularly safety must be interpreted cautiously. This narrative review aims to present the evidence surrounding the use of currently available pediatric SADs in routine anesthetic practice.
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Affiliation(s)
- Michelle C White
- Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Marlborough Street, Bristol, UK.
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Nicolai T. Management of the upper airway and congenital cystic lung diseases in neonates. Semin Fetal Neonatal Med 2009; 14:56-60. [PMID: 18835231 DOI: 10.1016/j.siny.2008.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital upper airway obstruction can pose difficult problems immediately after birth. Newer strategies to maintain the airway in such situations include pharyngeal ventilation, the laryngeal mask airway and flexible fibreoptic intubation. These methods have decreased the potential for malformations such as Pierre Robin sequence to cause perinatal hypoxia. The most devastating upper airway problem is total obstruction at the supraglottic, glottic or tracheal level without tracheo-oesophageal communication. This can usually be detected prenatally and its management may include the use of the EXIT (ex-utero intrapartum) procedure. Congenital space-occupying lesions of the lung can be detected prenatally with ultrasound. Their management must be individualised, as their pre- and postnatal development is difficult to predict. Very large lesions can lead to lung hypoplasia or fetal hydrops. Management may include prenatal surgery, shunting and, rarely, an EXIT procedure during birth. A few children may require extracorporeal membrane oxygenation postnatally.
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Affiliation(s)
- T Nicolai
- University Children's Hospital, Dr. v. Haunersches Kinderspital, Munich, Germany.
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Monclus E, Garcés A, Artés D, Mabrock M. Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway. Paediatr Anaesth 2008; 18:663-6. [PMID: 18482239 DOI: 10.1111/j.1460-9592.2008.02589.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
For a predicted difficult airway, oral intubation techniques are well established in pediatric anesthesia, but nasotracheal intubation remains a problem. There are many reports concerning this, but the risk of bleeding, added to the lack of cooperation make this procedure difficult and hazardous. We describe a modification of the nasal intubation technique in two stages. First an oral intubation and then exchanging the oral for a nasal tube, in the case of a 13-year-old boy affected by an advanced stage of cherubism. Oral intubation using a laryngeal mask technique has already been reported, but problems appear during the exchange procedure and even more when direct laryngoscopy is impossible. Fiberscopic control of the exchange, and the introduction of a Cook Exchange Catheter into the trachea through the oral tube before withdrawal, permits oxygenation of the patient and acts as a guide for oral tube reintroduction if required.
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Affiliation(s)
- Enric Monclus
- Hospital Sant Joan de Deu - Anesthesia, Barcelona, Spain.
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Youngquist S, Gausche-Hill M, Burbulys D. Alternative airway devices for use in children requiring prehospital airway management: update and case discussion. Pediatr Emerg Care 2007; 23:250-8; quiz 259-61. [PMID: 17438442 DOI: 10.1097/pec.0b013e31803f7552] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This manuscript reviews the latest literature on alternative airways for use in children requiring prehospital airway management. Case discussions serve as a springboard for discussion of alternatives to bag-mask ventilation and endotracheal intubation for management of ventilation in infants and children in the prehospital setting. Few airway procedures have been studied with any rigor in this setting, and most of the data that are available are extrapolated from adults. Laryngeal mask airway may be the best alternative airway with the most promise to add to the armamentarium of the prehospital provider, but no controlled trial to date has been conducted.
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Affiliation(s)
- Scott Youngquist
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, CA 90509, USA
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Cain JM, Mason LJ, Martin RD. Airway management in two of newborns with Pierre Robin Sequence: the use of disposable vs multiple use LMA for fiberoptic intubation. Paediatr Anaesth 2006; 16:1274-6. [PMID: 17121559 DOI: 10.1111/j.1460-9592.2006.01991.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this article, we discuss the use of LMAs as a conduit to intubate the trachea of two Pierre Robin Sequence infants. Multiple use LMAs will admit larger diameter tracheal tubes (TT) than their disposable counterparts. Increased friction with the surface of the TT makes passing even small diameter tubes through the lumen of the disposable LMA difficult.
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Affiliation(s)
- Judi M Cain
- Department of Anesthesia, Loma Linda University, Loma Linda, CA, USA.
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Abstract
Airway management in newborns, infants, and children is a challenge to anesthesia practitioners due to the particular anatomic and physiological characteristics. The larynx is positioned more cephalad, the occiput is protuberant, and the neck is short, which makes a special position for anesthesia induction necessary. The high respiratory frequency due to high oxygen demand and carbon dioxide production has to be taken into consideration during manual as well as mechanical ventilation. Different devices are available for airway management. Simple mask ventilation can be improved by a Wendl tube. The classic laryngeal mask can be recommended as a safe airway device in many indications, specifically in children with an upper respiratory airway infection. If intubation is indicated, an optimal size and position of the endotracheal tube has to be provided. Fiberoptic endotracheal intubation is recommended if a difficult airway is known or anticipated due to a craniofacial syndrome.
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Affiliation(s)
- C Höhne
- Kliniken für Anästhesiologie und operative Intensivmedizin, Charitè-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin.
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Platis CM, Wasersprung D, Kachko L, Tsunzer I, Katz J. Anesthesia management for the child with Sanjad-Sakati syndrome. Paediatr Anaesth 2006; 16:1189-92. [PMID: 17040310 DOI: 10.1111/j.1460-9592.2006.01981.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Sanjad-Sakati syndrome (SSS) is a rare genetic disorder characterized by congenital hypoparathyroidism, hypocalcemia and hyperphosphatemia, seizures, severe intrauterine and postnatal growth failure, dwarfism, mental retardation, dysmorphic features including retromicrognathia and abnormal dentition and increased susceptibility to infection. It is mainly confined to children in the Middle-East countries. We report the anesthesia management of a 12-year-old boy with SSS for dental treatment, and discuss the anesthesia implications of this disorder.
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Affiliation(s)
- Cari M Platis
- Department of Anesthesia, Schneider Children's Medical Center of Israel, Tel Aviv, Israel.
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Yilmaz AS, Gürkan Y, Toker K, Solak M. Laryngeal mask airway-guided fiberoptic tracheal intubation in a 1200-gm infant with difficult airway. Paediatr Anaesth 2005; 15:1147-8. [PMID: 16324044 DOI: 10.1111/j.1460-9592.2005.01724.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Holm-Knudsen R, Eriksen K, Rasmussen LS. Using a nasopharyngeal airway during fiberoptic intubation in small children with a difficult airway. Paediatr Anaesth 2005; 15:839-45. [PMID: 16176311 DOI: 10.1111/j.1460-9592.2004.01566.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Induction of anesthesia and tracheal intubation in small children with a difficult airway is a challenging task. We report the experience with a procedure based on sevoflurane inhalation via a nasopharyngeal airway inserted early during induction before airway obstruction occurs. A pediatric fiberscope is used to perform a nasotracheal intubation via the opposite nostril. METHODS All small children with suspected or known difficult airway needing tracheal intubation were scheduled for a fiberoptic intubation following the described protocol. RESULTS In 3 years, we performed 27 successful fiberoptic guided tracheal intubations in 19 children, median age 8.2 months (1.0-39.1 months) and median weight 7.6 kg (3.0-15.0 kg). The optimal depth for placement of the nasopharyngeal airway was found to be 8.0 cm (7.0-8.5 cm) from the nostril in the first year of life and 8.5 cm (8.0-10 cm) in the second year. Oxygenation was sufficient during the entire procedure in all cases except one child who had short-lasting laryngeal spasm caused by instillation of lidocaine during light anesthesia. The duration of fiberoptic intubation was significantly shorter when performed by an experienced anesthesiologist (55 s vs. 120 s), but there was no significant correlation between the duration of fiberoscopy and oxygen saturation during fiberoscopy or endtidal CO(2) after intubation. CONCLUSION The combination of nasopharyngeal airway and fiberoptic guided tracheal intubation seems to be a reliable and safe procedure for managing the difficult airway in small children.
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Affiliation(s)
- Rolf Holm-Knudsen
- Department of Anaesthesia and Operating Theatre Services, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej, Copenhagen, Denmark.
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Todd DW. Anesthetic Considerations for the Obese and Morbidly Obese Oral and Maxillofacial Surgery Patient. J Oral Maxillofac Surg 2005; 63:1348-53. [PMID: 16122600 DOI: 10.1016/j.joms.2005.05.307] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The purpose of this article is to review the problems of anesthetic management of the obese patient and review current literature on this topic. Obesity is associated with a wide spectrum of medical problems. Anesthetic management requires being familiar with the pathophysiologic changes associated with obesity as well as the specific management issues that can arise. We will review recommendations from the literature on anesthesia management as they apply to the oral and maxillofacial surgeon.
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Szmuk P, Matuszczeak M, Carlson RF, David Warters R, Rabb MF, Ezri T. Use of CobraPLA for airway management in a neonate with Desbuquois syndrome. Case report and anesthetic implications. Paediatr Anaesth 2005; 15:602-5. [PMID: 15960646 DOI: 10.1111/j.1460-9592.2005.01489.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present the anesthetic management of an infant with Desbuquois syndrome (a rare form of micromelic dwarfism) with a possible difficult airway. The anesthetic implications of this syndrome are presented. The airway was managed with a new supraglottic device - the CobraPLA. Although intubation through this device was not possible in this instance, CobraPLA provided a satisfactory supraglottic airway. It was easy to insert and provided satisfactory conditions for positive pressure ventilation. The CobraPLA provides another option for airway management.
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Affiliation(s)
- Peter Szmuk
- Department of Anesthesiology, University of Texas Medical School at Houston, TX 77030, USA.
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Abstract
We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.
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Affiliation(s)
- Andreas Machotta
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum
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