Advanced airway management

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.

Fetus-in-Fetu Airway Teratoma Management of a Newborn in a Low-Resource Country: A Case Report

A term baby was delivered by cesarean and found to have an unexpected large teratoma attached to its mouth. Surgical excision was planned within 24 hours. Anesthesia concern of airway control required multidisciplinary team consultation, airway and patient preparation, and anticipation for failure. Challenging airway cases in low-resource countries can be successfully managed with deliberate attention to detail, preparation, and experience.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Pediatric airway management

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.

Prehospital pediatric King LT-D use: a pilot study

OBJECTIVE

To determine whether prehospital providers can successfully place a pediatric King laryngeal tube (LT-D) and ventilate a Laerdal SimBaby pediatric simulator during a respiratory arrest simulation.

METHODS

We studied the ability of 45 paramedics and flight nurses to place the pediatric King LT-D in a SimBaby manikin. For the purposes of this study, paramedics and flight nurses were considered equivalent, because in this air medical system they have the same scope of practice in regard to airway skills. Because the participants had previous training and field experience with the adult King LT-D, we limited pediatric King LT-D training to our standard adult training plus selecting the correct size and inflation volumes for the device. Outcomes included rate of successful pediatric King LT-D placement, number of attempts to correctly place the tube, and time to first adequate ventilation. The subjects were evaluated on airway management using an 11-point skill test. A score of 8 or greater (≥ 73%) was considered passing. The subjects indicated their perceptions and preferences for the pediatric King LT-D using a five-point Likert scale. Data were analyzed using descriptive statistics.

RESULTS

Crew members successfully placed the pediatric King LT-D 95.5% (43/45) of the time. The median number of attempts was one. Four subjects required a second attempt; two of these subjects failed at placement. Mean time to placement was 34 seconds (95% confidence interval [CI]: 26.4-67.3 sec). Ninety percent of the participants (40/45) successfully completed the skill test, with a mean score of 78.2% (95% CI: 73.6-82.7). The subjects strongly agreed that their previous training on the adult King LT-D and using it in the field had adequately prepared them to use the pediatric King LT-D. The subjects agreed that the pediatric King LT-D was easier to place than a pediatric endotracheal tube; they strongly agreed that they would use the pediatric King LT-D as an alternative airway. The participants disagreed that they would prefer the pediatric King LT-D as a primary means of securing pediatric airways.

CONCLUSIONS

The pediatric King LT-D was quickly and reliably placed. Providers perceived the pediatric King LT-D to be easier to use than pediatric endotracheal intubation in this setting.