Do we need a new muscle relaxant in paediatrics?

Paediatric airway management: What is new?

Airway management plays a pivotal role in Paediatric Anaesthesia. Over the last two decades many improvements in this area have helped us to overcome this final frontier. From an era where intubation with a conventional laryngoscope or blind nasal intubation was the only tool for airway management, we have come a long way. Today supraglottic airway devices have pride of place in the Operating Room and are becoming important airway devices used in routine procedures. Direct and indirect fibreoptic laryngoscopes and transtracheal devices help us overcome difficult and previously impossible airway situations. These developments mean that we need to update our knowledge on these devices. Also much of our basic understanding of the physiology and anatomy of the paediatric airway has changed. This article attempts to shed light on some of the most important advances/opinions in paediatric airway management like, cuffed endotracheal tubes, supraglottic airway devices, video laryngoscopes, rapid sequence intubation, the newly proposed algorithm for difficult airway management and the role of Ex Utero Intrapartum Treatment (EXIT) procedure in the management of the neonatal airway.

[Intraosseous infusion. An important technique also for paediatric anaesthesia]

Timely establishment of venous access in infants and toddlers can prove a particularly challenging task. Since the 1940s the technique of intraosseous infusion has established itself as a valuable alternative means for rapid, efficient and safe delivery of drugs and fluids to critically ill children. Whereas international guidelines for paediatric emergency medical care have assigned intraosseous infusion a high priority, most anaesthetists utilize this well-proven technique with great reluctance. This article describes the technique of intraosseous infusion, introduces two different cannulation systems, and discusses its potential indications in paediatric anaesthesia, based on current emergency medical care guidelines as well as some of our own case studies. In particular, children with acutely life-threatening conditions, such as circulatory arrest, laryngospasm, acute airway haemorrhage, hypovolaemic shock or hypothermia secondary to extensive burns, should receive an intraosseous cannula if intravenous access cannot be rapidly established. Future discussion may reveal whether a transiently inserted intraosseous infusion would also be indicated if the child with difficult or impossible venous access presents without acute life-threatening conditions for anaesthesia. Successful application of the intraosseous infusion technique requires immediate access to the necessary equipment, intensive education, continuous training and clear guidelines for its application in an anaesthesia department.

Regional anaesthetic techniques for neonatal surgery: indications and selection of techniques

The goal of neonatal care is to optimise the outcome of term and preterm infants with minimal suffering. Neonates are rare patients for the anaesthetist, therefore personal and even global experiences are limited. This chapter focuses on strategies for dealing with common clinical situations, e.g. heel lancing, obtaining vascular access, circumcision, hernia repair and pyloric stenosis, as well as major neonatal surgery. With the exception of heel lancing, regional techniques are useful in all cases. However, a careful risk-benefit analysis is mandatory, especially when considering more invasive techniques such as epidural catheters.