First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial.

BACKGROUND: Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy. METHODS: In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432. FINDINGS: Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028). INTERPRETATION: Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications. FUNDING: Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.

Analysis of One- to 21-Year-Old Patients Preplanned for Hospital Admission After Dental Surgery.

Purpose: The purposes of this study were to: (1) describe patients preplanned for admission to the hospital after dental treatment under general anesthesia (GA) and compare patients who were admitted to those not admitted; (2) describe patients with unplanned admission to the hospital after dental treatment under GA; and (3) refine the criteria used for preplanning patients for admission.
Methods: Records of patients preplanned for admission following dental GA at a major children's hospital between January 1, 2015, and June 30, 2017 were reviewed.
Results: Pediatric dentists treated 948 patients. Most patients (84 percent) were planned for day surgery (n=792; two were admitted postoperatively [0.3 percent]). Sixteen percent (n=156 patients) were preplanned for hospital admission after surgery and 62 percent (n=97) of these patients were admitted. Anticipated challenges with analgesia, nutrition, or hydration were reasons for preplanned admission significantly associated with hospital admission (P <.01). Demographics, body mass index, physical status classification, and apnea-hypopnea index were not significantly associated with admission. Significant differences in medical support provided in the admitted versus non-admitted cohorts were: non-opiate analgesics (P <0.01); opiates (P =0.02); antiemetics (P =0.01); airway support (P =0.05); and intravenous hydration (P <0.01).
Conclusion: Among patients preplanned for admission to the hospital following dental surgery, 62 percent were admitted; these patients received significantly more intravenous fluids, antiemetic and/or analgesic medications, and airway support than patients not admitted.

Infection prevention in pediatric anesthesia practice.

Healthcare-associated infections are an important source of morbidity and mortality in pediatric patients. Anesthesiologists have a unique role in infection prevention. Hand hygiene and anesthesia workspace decontamination decrease infection rates in surgical patients. Standard protocols exist for insertion and handling of central lines, arterial lines, and regional procedures, which should be strictly adhered to in order to prevent infectious complications. Temperature control and timely administration of antibiotics contribute to the prevention of surgical site infections. Education, culture shift, staff engagement, and effective change management are necessary for successful implementation of infection prevention strategies.