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Engelhardt T, Disma N. Paediatric anaesthesia: it is not only what you do, but how you do it. THE LANCET. RESPIRATORY MEDICINE 2024; 12:501-503. [PMID: 38788749 DOI: 10.1016/s2213-2600(24)00145-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Affiliation(s)
- Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC H4A 3J1, Canada.
| | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
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2
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Tsuboi K, Asai M, Nakamura T, Ninagawa J, Ono H, Kasuya S. Combination of high-flow nasal oxygen and ketamine/dexmedetomidine sedation for diagnostic catheterization in a child with pulmonary arterial hypertension: a case report. JA Clin Rep 2024; 10:16. [PMID: 38386179 PMCID: PMC10884373 DOI: 10.1186/s40981-024-00699-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024] Open
Abstract
Pulmonary hypertension is associated with significant risk of perioperative life-threatening events. We present a case of a 12-year-old child with severe pulmonary arterial hypertension who successfully underwent diagnostic cardiac catheterization under ketamine and dexmedetomidine sedation with the support of high-flow nasal oxygen. Ketamine and dexmedetomidine are reported to have minimal effect on pulmonary vasculature in children with pulmonary hypertension and can be safely used in this population along with its lack of respiratory depression. Positive pressure generated by high-flow nasal oxygen improves upper airway patency, prevents micro-atelectasis, and is shown to improve the effectiveness of ventilation and oxygenation in patients under sedation breathing spontaneously. The presented strategy may contribute to enhancing the safety and effectiveness of procedural sedation for children with life-threatening pulmonary hypertension.
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Affiliation(s)
- Kaoru Tsuboi
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan.
| | - Misuzu Asai
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Toshiki Nakamura
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Japan
| | - Jun Ninagawa
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Hiroshi Ono
- Department of Cardiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Shugo Kasuya
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
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3
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Sequera-Ramos L, Garcia-Marcinkiewicz A, Riva T, Fuchs A. Noninvasive ventilation in children: A review for the pediatric anesthesiologist. Paediatr Anaesth 2022; 32:262-272. [PMID: 34877751 DOI: 10.1111/pan.14364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/19/2023]
Abstract
Preserving adequate respiratory function is essential in the perioperative period. Mechanical ventilation with endotracheal intubation is widely used for this purpose. In select patients, noninvasive ventilation (NIV) may be an alternative to invasive ventilation or may complement respiratory management. NIV is used to provide ventilatory support and increase gas exchange at the alveolar level without the use of an invasive artificial airway such as an endotracheal tube or tracheostomy. NIV includes both continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation. Indications for NIV range from acute hypoxic respiratory failure in the intensive care unit or the emergency department, to chronic respiratory failure in patients with neuromuscular disease with nocturnal hypoventilation. In the perioperative setting, NIV is commonly applied as CPAP, and bilevel positive airway pressure (BPAP). There are limited data on the role of NIV in children in the perioperative setting, and there are no clear guidelines regarding optimal timing of use and pressure settings of perioperative NIV. Contraindications to the use of NIV include reduced level of consciousness, apnea, severe respiratory distress, and inability to maintain upper airway patency or airway protective reflexes. Common problems encountered during NIV involve airway leaks and asynchrony with auto-triggering. High-flow nasal oxygen (HFNO) has emerged as an alternative to NIV when trying to decrease the work of breathing and improve oxygenation in children. HFNO delivers humidified and heated oxygen at rates between 2 and 70 L/min using specific nasal cannulas, and flows are determined by the patient's weight and clinical needs. HFNO can be useful as a method for preoxygenation in infants and children by prolonging apnea time before desaturation, yet in children with decreased minute ventilation or apnea HFNO does not improve alveolar gas exchange. Clinicians experienced with these devices, such as pediatric intensivists and pulmonary medicine specialists, can be useful resources for the pediatric anesthesiologist caring for complex patients on NIV.
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Affiliation(s)
- Luis Sequera-Ramos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Unit for Research & Innovation in Anaesthesia, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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4
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Wang JT, Peyton J, Hernandez MR. Anesthesia for pediatric rigid bronchoscopy and related airway surgery: Tips and tricks. Paediatr Anaesth 2022; 32:302-311. [PMID: 34877742 DOI: 10.1111/pan.14360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022]
Abstract
Bronchoscopy-guided diagnostic and interventional airway procedures are gaining in popularity and prominence in pediatric surgery. Many of these procedures have been used successfully in the adult population but have not been used in children due to a lack of appropriately sized instruments. Recent technological advances have led to the creation of instruments to enable many more diagnostic and therapeutic procedures to be done under bronchoscopic guidance. These procedures vary significantly in their length and invasiveness and require vastly different anesthetic plans that must be easily adapted to situational and procedural changes. In addition to close communication between the anesthesiology and procedural teams; an understanding of the type of procedure, anesthetic requirements, and potential patient risks is paramount to a successful anesthetic. This review will focus on new rigid bronchoscopic procedures, goals for their respective anesthetic management, and unique tips and trick for how to maintain adequate oxygenation and ventilation in each scenario.
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Affiliation(s)
- Jue T Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael R Hernandez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Templeton TW, Sommerfield D, Hii J, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options. Paediatr Anaesth 2022; 32:217-227. [PMID: 34897894 DOI: 10.1111/pan.14376] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/17/2022]
Abstract
Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at-risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition.
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Affiliation(s)
- Thomas Wesley Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, School of Medicine, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Justin Hii
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Aine Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Termerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Britta S von Ungern-Sternberg
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, School of Medicine, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Johansen M, Daniel SJ, Engelhardt T. Use of nasal high flow in upper airway surgery with laser. Paediatr Anaesth 2022; 32:90-91. [PMID: 34709691 DOI: 10.1111/pan.14317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/25/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mathias Johansen
- Department of Pediatric Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada.,Department of Otolaryngology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Sam J Daniel
- Department of Pediatric Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada.,Department of Otolaryngology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Thomas Engelhardt
- Department of Pediatric Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada.,Department of Otolaryngology, Montreal Children's Hospital, Montreal, QC, Canada
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Kim JY, Bae J, Lee KH, Kang L, Kim KN, Jeong MA. High-flow nasal cannula application in an infant patient with laryngomalacia during general anesthesia: A case report. Medicine (Baltimore) 2021; 100:e28102. [PMID: 34889265 PMCID: PMC8663912 DOI: 10.1097/md.0000000000028102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/16/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Laryngomalacia is defined as the collapse of supraglottic structures and can cause not only strider but also trigger difficulties with ventilation and endotracheal intubation during anesthesia management. High-flow nasal cannula (HFNC) has been used to manage patients at high risk of hypoxemia in the intensive care unit; however, limited literature information is available for the application of HFNC to infant patients with laryngomalacia during anesthesia practice. PATIENT CONCERNS A 2-month-old male infant was scheduled to undergo surgery for inguinal hernia and undescended testis with general anesthesia. DIAGNOSIS The patient had subcostal retraction while breathing and frequent oxygen desaturation events and was diagnosed laryngomalacia. INTERVENTIONS After the patient was supplied oxygen via HFNC and then given general anesthesia, the initial 2 attempts of endotracheal intubation with a rigid laryngoscope were unsuccessful because the vocal cords were obscured by the epiglottis. A third intubation attempt was performed and successful with a 3.0-sized, uncuffed endotracheal tube within 20 minutes of the initial attempt. OUTCOMES No airway complications emerged and oxygen saturation remained at greater than 98% during general anesthesia. The patient was discharged 5 days after surgery without any adverse side effects. LESSONS Continuous oxygenation via HFNC is a good choice to prevent desaturation during difficult tracheal intubations in infant patients with laryngomalacia. This device is expected to be useful for intubation not only in patients with laryngomalacia, but also in infant patients with a predicted high risk of oxygen desaturation events during general anesthesia.
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Sohn L, Peyton J, von Ungern-Sternberg BS, Jagannathan N. Error traps in pediatric difficult airway management. Paediatr Anaesth 2021; 31:1271-1275. [PMID: 34478189 DOI: 10.1111/pan.14289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/13/2021] [Accepted: 08/28/2021] [Indexed: 02/04/2023]
Abstract
Difficult airway management in children is associated with significant morbidity. This narrative review on error traps in airway management aims to highlight the common pitfalls and proposes solutions to optimize best practices for pediatric difficult airway management. We have categorized common errors of pediatric difficult airway management into three main error traps: preparation, performance, and proficiency, and present potential strategies to improve patient safety and successful tracheal intubation in infants and children with difficult airways.
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Affiliation(s)
- Lisa Sohn
- Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James Peyton
- Department of Anesthesia, Anesthesiology, Critical Care and Pain Medicine, Boston Children s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Britta S von Ungern-Sternberg
- Department of Anesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia.,The University of Western Australia, Perth, WA, Australia
| | - Narasimhan Jagannathan
- Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Report of two cases of endobronchial tumour mass resection in children. Can J Anaesth 2021; 68:1368-1372. [PMID: 34128203 DOI: 10.1007/s12630-021-02055-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Anesthesia for endotracheal tumour mass resection in pediatric patients is a rare, complex, and high-risk procedure. The purpose of this case report is to emphasize the importance of multidisciplinary team collaboration and close communication during the perioperative management of shared airway surgery. CLINICAL FEATURES A six-year-old boy with no previous history of comorbidity and a 13-yr-old boy with a six-month history of upper respiratory tract infection, refractory asthma, chronic wheeze, and exercise-related dyspnea presented for acute endobronchial tumour mass resection. Decreased pulmonary function, religious beliefs (Jehovah's Witness), risk of intraluminal bleeding, and imminent complete airway collapse constitute areas of specific interest. CONCLUSION Anesthesia for endotracheal tumour mass resection in pediatric patients is a rare, complex, and high-risk procedure. Decreased pulmonary function and low respiratory reserves combined with the need for extensive surgical airway access warrants multidisciplinary team collaboration and close communication. Maintaining spontaneous respiration is paramount to reduce the risk of hypoxemia-induced adverse events and preoperative considerations should include the possible need for extracorporeal membrane oxygenation. Finally, the use of nasal high flow for shared airway surgery shows promising prospects warranting further investigation.
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Abstract
PURPOSE OF REVIEW Children are at risk of severe hypoxemia in the perioperative period owing to their unique anatomy and physiology. Safe and effective airway management strategies are therefore key to the practice of pediatric anesthesia. The goal of this review is to highlight recent publications (2019-2021) aimed to advance pediatric airway safety and to highlight a proposed simple, pediatric-specific, universal framework to guide clinical practice. RECENT FINDINGS Recent investigations demonstrate that infants with normal and difficult airways experience high incidences of multiple laryngoscopy attempts and resulting hypoxemia. Video laryngoscopy may improve tracheal intubation first attempt success rate in infants with normal airways. In infants with difficult airways, standard blade video laryngoscopy is associated with higher first attempt success rates over non-standard blade video laryngoscopy. Recent studies in children with Pierre Robin sequence and mucopolysaccharidoses help guide airway equipment and technique selection. Department airway leads and hospital difficult airway services are necessary to disseminate knowledge, lead quality improvement initiatives, and promote evidence-based practice guidelines. SUMMARY Pediatric airway management morbidity is a common problem in pediatric anesthesia. Improvements in individual practitioner preparation and management strategies as well as systems-based policies are required. A simple, pediatric-specific, universal airway management framework can be adopted for safe pediatric anesthesia practice.
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Disma N, Virag K, Riva T, Kaufmann J, Engelhardt T, Habre W. Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study. Br J Anaesth 2021; 126:1173-1181. [PMID: 33812665 DOI: 10.1016/j.bja.2021.02.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Unit for Research & Innovation in Anaesthesia, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy.
| | - Katalin Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Thomas Riva
- Department of Anaesthesiology and Pain Therapy, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
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Sago T, Watanabe K, Kawabata K, Shiiba S, Maki K, Watanabe S. A Nasal High-Flow System Prevents Upper Airway Obstruction and Hypoxia in Pediatric Dental Patients Under Intravenous Sedation. J Oral Maxillofac Surg 2021; 79:539-545. [DOI: 10.1016/j.joms.2020.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 01/17/2023]
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13
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von Ungern-Sternberg BS, Engelhardt T. Life is really simple, but we insist on making it complicated (Confucius). Paediatr Anaesth 2020; 30:203. [PMID: 32248656 DOI: 10.1111/pan.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Britta S von Ungern-Sternberg
- Medical School, The University of Western Australia, Perth, WA, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Telethon Kid's Institute, Perth, WA, Australia
| | - Thomas Engelhardt
- Department of Anesthesia, McGill University Health Center, Montreal Children's Hospital, Montreal, QC, CA
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