Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing a strategy that optimizes the likelihood of safe extubation. This includes team-focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

A Novel 3-Dimensional Printing Fabrication Approach for the Production of Pediatric Airway Models.

BACKGROUND: Pediatric airway models currently available for use in education or simulation do not replicate anatomy or tissue responses to procedures. Emphasis on mass production with sturdy but homogeneous materials and low-fidelity casting techniques diminishes these models' abilities to realistically represent the unique characteristics of the pediatric airway, particularly in the infant and younger age ranges. Newer fabrication technologies, including 3-dimensional (3D) printing and castable tissue-like silicones, open new approaches to the simulation of pediatric airways with greater anatomical fidelity and utility for procedure training. METHODS: After ethics approval, available/archived computerized tomography data sets of patients under the age of 2 years were reviewed to identify those suitable for designing new models. A single 21-month-old subject was selected for 3D reconstruction. Manual thresholding was then performed to produce 3D models of selected regions and tissue types within the dataset, which were either directly 3D-printed or later cast in 3D-printed molds with a variety of tissue-like silicones. A series of testing mannequins derived using this multimodal approach were then further refined following direct clinician feedback to develop a series of pediatric airway model prototypes. RESULTS: The initial prototype consisted of separate skeletal (skull, mandible, vertebrae) and soft-tissue (nasal mucosa, pharynx, larynx, gingivae, tongue, functional temporomandibular joint [TMJ] "sleeve," skin) modules. The first iterations of these modules were generated using both single-material and multimaterial 3D printing techniques to achieve the haptic properties of real human tissues. After direct clinical feedback, subsequent prototypes relied on a combination of 3D printing for osseous elements and casting of soft-tissue components from 3D-printed molds, which refined the haptic properties of the nasal, oropharyngeal, laryngeal, and airway tissues, and improved the range of movement required for airway management procedures. This approach of modification based on clinical feedback resulted in superior functional performance. CONCLUSIONS: Our hybrid manufacturing approach, merging 3D-printed components and 3D-printed molds for silicone casting, allows a more accurate representation of both the anatomy and functional characteristics of the pediatric airway for model production. Further, it allows for the direct translation of anatomy derived from real patient medical imaging into a functional airway management simulator, and our modular design allows for modification of individual elements to easily vary anatomical configurations, haptic qualities of components or exchange components to replicate pathology.

Staged intraperitoneal brachytherapy and hyperthermic intraperitoneal chemotherapy in an adolescent: novel anesthetic challenges for pediatric anesthetists.

Newer techniques that have found a place in cancer management in adults are offered far less commonly in pediatric patients. We present a case of a patient with recurrent Wilms' tumor managed with a novel combination of cytoreductive surgery, intraperitoneal brachytherapy, and subsequent hyperthermic intraperitoneal chemotherapy. Each stage presents challenges that the pediatric anesthetist is unlikely to have faced before. Such cases require flexibility and thorough planning to manage the combination of major surgery, remote anesthesia with brachytherapy and hyperthermic chemotherapy with its potential for metabolic derangement, significant fluid shifts, analgesic care, and potential exposure of staff to cytotoxic agents. Comprehensive care can be offered in pediatric centers.

Exploring anaesthetists' views on the carbon footprint of anaesthesia and identifying opportunities and challenges for reducing its impact on the environment.

A shift in practice by anaesthetists away from anaesthetic gases with high global warming potential towards lower emission techniques (e.g. total intravenous anaesthesia) could result in significant carbon savings for the health system. The purpose of this qualitative interview study was to understand anaesthetists' perspectives on the carbon footprint of anaesthesia, and views on shifting practice towards more environmentally sustainable options. Anaesthetists were recruited from four hospitals in Western Sydney, Australia. Data were organised according to the capability-opportunity-motivation model of behaviour change. Twenty-eight anaesthetists were interviewed (July-September 2021). Participants' age ranged from 29 to 62 years (mean 43 years), 39% were female, and half had completed their anaesthesia training between 2010 and 2019. Challenges to the wider use of greener anaesthetic agents were identified across all components of the capability-opportunity-motivation model: capability (gaps in clinician skills and experience, uncertainty regarding research evidence); opportunity (norms, time, and resource pressures); and motivation (beliefs, habits, responsibility and guilt). Suggestions for encouraging a shift to more environmentally friendly anaesthesia included access to education and training, implementing guidelines and audit/feedback models, environmental restructuring, improving resource availability, reducing low value care, and building the research evidence base on the safety of alternative agents and their impacts on patient outcomes. We identified opportunities and challenges to reducing the carbon footprint of anaesthesia in Australian hospitals by way of system-level and individual behavioural change. Our findings will be used to inform the development of communication and behavioural interventions aiming to mitigate carbon emissions of healthcare.

Learner and educator experiences and priorities in paediatric airway education: A qualitative study.

Paediatric airway management is a challenging area of anaesthesia practice to learn. Techniques and skills required need modification from adult practice and gaining experience through exposure takes considerable time. Preparation to manage airway emergencies can be particularly difficult as these events are rare in paediatric practice. This study aimed to examine what educational approaches health professionals of varying backgrounds find useful when learning or teaching paediatric airway management. This qualitative study involved the conduct of five interdisciplinary focus groups; each group consisted of four to six health professionals from nursing, anaesthetic, simulation and critical care backgrounds. After transcription, focus group content was analysed using a qualitative method to identify common themes expressed within the interviews. Five themes were most prominent. These included the high value of hands-on learning, the challenges created by variability in exposure, the importance of developing basic airway skills, the potential for simulation to cover rare situations, and the problems of current airway models. These themes were evident in comments from both experienced and novice practitioners, clinicians with different subspecialty backgrounds and both medical and nursing staff. Learners and educators have similar priorities in airway education. This includes a strong recognition of the importance of spending time mastering basic airway techniques, a role for simulation in building non-technical skills and noted deficiencies in current airway models.

Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service.

BACKGROUND: Drowning patients may benefit from the advanced airway management capabilities that can be provided by physician staffed helicopter emergency medical services. The aim of this study is to describe paediatric drowning patients treated by such a service examining tasking systems, initial physiology at the incident scene, survival and neurological outcome. METHODS: Retrospective analysis of paediatric drowning victims over a 5- year period. Case identification system, patient age, site of drowning, presence or absence of cardiac output, first Glasgow Coma Scale (GCS) score and interventions were collected from prehospital notes, and survival and neurological outcomes from hospital and rehabilitation notes. RESULTS: The P-HEMS direct case identification system operating in parallel with a central control system identified all severe drowning cases but 3 of 7 cases (43%) were missed when the central control system operated in isolation. All severe drowning cases (22) identified for P-HEMS response were intubated and transported directly to a paediatric specialist centre. Intubation required adjuvant anaesthesia in 10 (45%) cases. All children with GCS greater than eight on arrival of the P-HEMS survived neurologically intact. Seven of eight children with a GCS between four and seven survived without neurological impairment and all children with a GCS greater than three survived. Four of twelve asystolic children survived including one child who at 18 months post drowning is neurologically normal. All children who survived had return of spontaneous circulation prior to arrival in the emergency department. CONCLUSIONS: P-HEMS played a significant role in the management of severe paediatric drowning in this case series. Requirement for P-HEMS only interventions were high and all identified cases were transferred directly to a paediatric specialist centre. Discontinuation of the P-HEMS direct case identication system that operated during the majority of the study period resulted in deterioration in system performance with some paediatric drowning cases subsequently not identified for P-HEMS response being transported to adult hospitals.

Prehospital paediatric emergencies treated by an Australian helicopter emergency medical service.

OBJECTIVES: The aim of this study was to describe the mechanism and severity of injuries in the paediatric population treated by an Australian helicopter emergency medical service and to examine the frequency and nature of interventions performed. This information is important for planning education and continuing professional development in prehospital medicine. METHODS: The study is a retrospective cohort analysis of 349 patients under the age of 16 treated by CareFlight in Sydney, Australia, between April 2007 and April 2012. Data collected included age, type of incident, medication and fluid administered, procedures performed, receiving hospital, 24 h and 30-day mortality and injuries sustained. RESULTS: Falls (33%), motor vehicle incidents (30%), sport injury (14%) and immersion injury (12%) were the most common mechanisms. A total of 27 children died within 30 days; nontrauma cases were proportionally overrepresented in the deaths. With respect to tasking, 59% cases involved a severely or significantly injured child. Among the children, 97% with a traumatic mechanism were transferred directly to a paediatric trauma centre.In addition, 81% of children had at least one intervention by the helicopter emergency medical services team at the incident scene, most commonly intravenous cannulation (61%), crystalloid bolus (29%), intubation (21%) and intravenous analgesia administration (15%). CONCLUSION: Paediatric prehospital patients can be of high dependency, requiring urgent critical care procedures. Training in prehospital medicine should include paediatrics. It is essential that practitioners maintain skills in venous access, airway management and provision of adequate analgesia in children.