Hypopharyngeal Perforation Mimicking Esophageal Atresia: A Case Report of an Extremely Low Birth Weight Infant Emphasizing the Need for Preoperative Endoscopy.

We report a case of an extremely low birth weight premature infant born at 27 weeks of gestation, transferred to our tertiary pediatric referral center for surgical repair of an esophageal atresia. Endoscopic evaluation before the start of surgery revealed a hypopharyngeal perforation, resulting in the false impression of esophageal atresia. If no tracheoesophageal fistula is found during tracheoscopy, esophagoscopy should be done before surgical intervention as the inability to pass a nasogastric tube into the stomach is not sufficiently reliable for a correct diagnosis of esophageal atresia.

Rapid and safe removal of foreign bodies in the upper esophagus in children using an optimized Miller size 3 video laryngoscope blade.

BACKGROUND: Foreign bodies lodged in the upper esophagus in children may result in life-threatening complications, especially with button batteries. Rapid removal is essential to prevent complications. Experts report that extraction with a suitable laryngoscope and a forceps is feasible under general anesthesia, but no further data had been available so far. AIMS: To study foreign body visualization and removal from the upper esophagus in children using a new optimized Miller size 3 blade video laryngoscope. METHODS: This prospective observational study was performed in three pediatric hospitals. The clinical observations were reported anonymously on an electronic spreadsheet after obtaining the informed consent from the parents or guardians. During the observational period from January 2019 to October 2020, all children with a foreign body lodged into the upper esophagus were eligible for participation and 22 cases were included. Main outcome measures were rates of successful removal and complications as well as duration of the procedure. Secondary outcome was subjective assessment regarding the quality of the visualization and the feasibility of the procedure. RESULTS: Success rate was 100% with no complications. Mean intervention and anesthesia times were 5 ± 4 minutes and 26 ± 25 minutes. Quality of visualization of the foreign body was judged as 'excellent' or 'good' in all cases and the feasibility of the procedure as 'without' or 'with little' effort in 95% of all cases. CONCLUSION: The new Miller size 3 video laryngoscope enables rapid, easy, and reliable extraction of foreign bodies when they are located in the upper part of the esophagus. As early removal of esophageal foreign bodies, especially with button batteries, prevents life-threatening complications, we suggest this technique as the first choice of treatment.

[Anaesthesia in Children and Adolescents with Disabilities]. / Anästhesie bei Kindern und Jugendlichen mit Behinderung.

Children and adolescents with disabilities have the right of full and effective participation and inclusion in society. Disability includes a wide range of long-term physical, mental, intellectual and sensory impairments for various reasons. In addition to the basic illness many children with disabilities have concomitant diseases. These diseases are decisive for the perioperative risk. Information from parents regarding their child's behavioural patterns and needs, signs of escalating anxiety and pain are important. Perioperative dialog with the parents is helpful and has positive effects also from parental point of view. Pharmacologic premedication is recommended. Induction of anaesthesia can be challenging and sometimes requires unconventional methods. Pain behaviour may be unusual. There are suitable scales that incorporate such behaviours.

[Health damages after ingestion of button batteries in childhood]. / Gesundheitsschäden nach Ingestion von Knopfzellbatterien im Kindesalter.

BACKGROUND: Exposure of children under 5 years to button batteries may result in severe corrosive injury, especially when they get stuck in the oesophagus. The injury is caused by the discharge current of the batteries. An increasing number of button battery ingestions have been described worldwide. OBJECTIVES: The aim of this study was to describe incidence and complications after battery ingestion in children in Germany. MATERIALS AND METHODS: Paediatric gastroenterologists and paediatric surgeons were asked to report complicated battery ingestions in children between 2011 and 2016 retrospectively. The survey was done using a structured questionnaire. In addition, button battery ingestion calls to a German poison centre were analysed retrospectively. RESULTS: In 116 cases the button battery was located in the oesophagus. Severe complications developed in 47 patients and 5 of these children died. Serious complications occurred also in children with removal of the button batteries within less than 3 h after the intake. The Freiburg poison centre received 258 paediatric ingestions of button batteries. Out of these, seven button batteries were stuck in the oesophagus and five in the nose causing corrosion injury. CONCLUSIONS: Serious complications and even death after button battery ingestion are described in Germany. Button batteries impacted in the oesophagus should be removed emergently to minimize corrosive injury. Because no symptoms or only slight discomfort are developed initially, awareness of button batteries as a unique corrosive hazard among the public and clinicians is an important requirement for prompt diagnosis and treatment resulting in a satisfactory outcome.

Transglottic corticosteroid injection for treatment of soft post-intubation subglottic stenosis: a retrospective analysis of 26 children.

PURPOSE: Surgical treatment is generally recommended for severe subglottic lesions following traumatic endotracheal intubation in children. An alternative approach is early transglottic corticosteroid administration to reduce scar formation and prevent the need for subsequent surgical intervention. This technique has been practiced successfully for several decades at the Children's Hospital of Cologne and the outcomes of 26 subsequent patients reviewed in this analysis. METHODS: All patients who underwent transglottic corticosteroid injection for treatment of post-intubation stridor and dyspnoea between 2012 and 2018 were identified and their records and endoscopy images analysed. Severity of the endoscopic findings was assessed using the Myer-Cotton classification (MCC) and an Expected Need for Surgical Intervention (ENSI) score (1 = inevitable; 2 = very likely necessary; 3 = probably avoidable and 4 = most likely not necessary) was recorded. Treatment was considered successful if the children had a complete resolution of clinical symptoms. RESULTS: A total of 26 patients with a median (range) age of 1.9 (0.02-7.2) years and weight of 9.8 (1.8-25) kg were identified and included into the analysis. Endoscopic images were available for 22 children. All children underwent transglottic corticosteroid injection prior to any potential surgical treatment. A total of 22 patients (85%) improved following transglottic corticosteroid injection including 4 of 5 patients with a MCC = 3 and ENSI = 1 avoiding surgical intervention. None of the patients experienced a deterioration of clinical symptoms or endoscopic findings. CONCLUSION: Transglottic corticosteroid injections as first-line treatment in children with severe post-endotracheal intubation trauma can successfully resolve symptoms and prevent invasive surgery.

[Safe Paediatric Anaesthesia: Update on Drug Safety]. / Kinderanästhesie mit Sicherheit: Update Medikamentensicherheit.

Drug errors occur in all areas of care. Due to age-group-specific characteristics and the need for dose calculation, the probability of errors in children increases compared to adults. The recognition of the fallibility of every supplier and the acceptance of security structures are essential. The article describes a catalogue of measures for drug safety suitable for everyday use.

[What to Do When a Child Is Choking?] / "Das Kind hat einen Fremdkörper verschluckt" ­ was tun?

Both ingestion and aspiration of foreign bodies are common events in children. If a child had something in his mouth and thereafter respiratory or swallowing complaints occur, both aspiration and ingestion are possible causes. Both events can be immediately life threatening or, if a direct threat is absent, cause significant long-term impairments for the children. Therefore, the identification of any possible threat is essential. This paper identifies the diagnostic and therapeutic options and needs that will ensure the best possible safety and the least possible consequential harm.

Development and Prospective Federal State-Wide Evaluation of a Device for Height-Based Dose Recommendations in Prehospital Pediatric Emergencies: A Simple Tool to Prevent Most Severe Drug Errors.

OBJECTIVE: Drug dosing errors pose a particular threat to children in prehospital emergency care. With the Pediatric emergency ruler (PaedER), we developed a simple height-based dose recommendation system and evaluated its effectiveness in a pre-post interventional trial as the Ethics Committee disapproved randomization due to the expected positive effect of the PaedER on outcome. METHODS: Pre-interventional data were retrospectively retrieved from the electronic records and medical protocols of the Cologne Emergency Medical Service over a two-year period prior to the introduction of the PaedER. Post-interventional data were collected prospectively over a six-year period in a federal state-wide open trial. The administered doses of either intravenous or intraosseous fentanyl, midazolam, ketamine or epinephrine were recorded. Primary outcome measure was the number and severity of drug dose deviation from recommended dose (DRD) based on the patient's weight. RESULTS: Fifty-nine pre-interventional and 91 post-interventional prehospital drug administrations in children were analyzed. The rate of DRD > 300% overall medications were 22.0% in the pre- and 2.2% in the post-interventional group (p < 0.001). All administrations of epinephrine occurred excessive (DRD > 300%) in pre-interventional and none in post-interventional patients (p < 0.001). CONCLUSIONS: The use of the PaedER resulted in a 90% reduction of medication errors (95% CI: 57% to 98%; p < 0.001) and prevented all potentially life-threatening errors associated with epinephrine administration. There is an urgent need to increase the safety of emergency drug dosing in children during emergencies. A simple height-based system can support health care providers and helps to avoid life-threatening medication errors.

Aortopexy offers surgical options for a variety of pathological tracheal conditions in paediatric patients.

OBJECTIVES: Aortopexy is widely used; however, many surgeons still regard it with suspicion. To date, there are only a few large series and minimal long-term data. Against this background, our goal was to report our experience, particularly with regard to the recent expansion of indications and modification of diagnostic routine and surgical strategy. METHODS: Between 1994 and 2012, 53 patients (mean age: 1.1 years; 5 weeks-10.2 years) were operated on. Tracheomalacia after the operation for oesophageal atresia was the main indication for aortopexy (74%), followed by tracheal compression by the innominate artery (17%) and other selected indications (9%). Computed tomography angiography has emerged in recent years as the method of choice for preoperative diagnosis. Median sternotomy has replaced lateral thoracotomy, and intraoperative bronchoscopy has become the standard. RESULTS: In contrast to magnetic resonance imaging, computed tomography angiography resulted in perfect visualization of the condition. Median sternotomy and simultaneous bronchoscopy led to immediate readjustment of the aortopexy sutures in 6 patients. There were no surgical deaths or serious morbidities. The mean follow-up was 4.9 (0.3-14.9) years. Two patients with additional complex diseases died during the follow-up period. In all survivors, symptoms improved markedly or disappeared. However, we observed an increased susceptibility to lower respiratory tract infections over the long-term (32%). CONCLUSIONS: Aortopexy is effective for treating tracheomalacia of different origins and other pathological conditions as well. Preoperative computed tomography angiography offers excellent visualization of the condition. Median sternotomy and intraoperative bronchoscopy provide a combination for reliable operative and long-term results. However, many patients still have an increased susceptibility to lower respiratory tract infections.

Quality of Life after Surgical Treatment for Esophageal Atresia: Long-Term Outcome of 154 Patients.

Background The short- and long-term surgical results in patients with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) have been described in depth from a physician's perspective. Contrarily, the perception and coping strategies of affected patients and their parents have rarely been reported. The aim of this study was to generate data on this matter. Patients and Methods A total of 154 patients who had operative reconstruction for EA between 1971 and 2012 were evaluated for demographic data, surgical technique, affection of daily life, and coping strategies. Results Gastroesophageal reflux (GER) symptoms were reported in 59% of cases with 33% requiring fundoplication. Regular bougienages of anastomotic strictures were necessary in 68% with 36% requiring repeated dilatations in the first postoperative year. Enteral nutrition via a nasogastric tube was performed in 66% after surgery. In 40%, the tube was needed until their sixth week of life. In 25%, nutritional support was necessary more than 1 year out of surgery. Quality of life in general was felt to be impaired according to the patients' parents in 50%. Regarding medical advice about long-term morbidities, more than 50% of the parents felt insufficiently advised. There were no statistical differences between the EA/TEF subtypes regarding GER symptoms, frequency of esophageal dilatations, eating behaviors, or support of the parents in feeding management. Conclusion Our observations indicate that a high percentage of EA/TEF patients and families require more intensive aftercare and support during the first year following primary reconstruction than previously thought. We observed a higher need for adequate parental information on long-term complications of their children compared with current practice.

Quality of handover in a pediatric postanesthesia care unit.

BACKGROUND: The quality of anesthetic handovers to postanesthesia care units (PACU) is known to be poor in adults, and only very limited reports are available regarding the quality of handovers in pediatric anesthesia. In particular, it is not known which and in what quality information is communicated. This current study investigated, therefore, the presence of any handover component as well as its consistency in a pediatric postanesthesia care unit. METHODS: This prospective observational study evaluated postoperative anesthetic handovers to a pediatric PACU using a detailed checklist, comprising 55 possible items. The main outcome measure was the proportion of information verbally transmitted in relation to the written documentation within the anesthesia record. RESULTS: Four hundred and forty-three handovers were observed with two handovers excluded due to missing data. Type of surgery (93% [95% CI 91-95]) and any intra-operative regional anesthesia (89% [95% CI 85-94]) were most frequently communicated. Items such as ASA-PS (3% [95% CI 2-5]) and fluid management (4% of cases [95% CI 2-6]) were rarely handed over. Eleven of the 55 items contained within the checklist were communicated in more than 70% of patients. CONCLUSIONS: The observed handovers to PACU staff were incomplete and missing important information. However, omission of essential information potentially compromises patient safety. A standardized universal mandatory handover protocol following pediatric anesthesia is required.

Tracheal intubation with the Bonfils fiberscope in the difficult pediatric airway: a comparison with fiberoptic intubation.

BACKGROUND: Fiberoptic intubation (FOI) is the gold standard for the tracheal intubation in adults with a difficult airway. However, this technique is more difficult in the narrow pediatric airway and the evaluation of alternative devices in children remains desirable. The Bonfils fiberscope (BF) is well described for the difficult airway, but no clinical data assessing its use in the difficult pediatric airway are available. METHODS: A controlled clinical study was conducted comparing BF and FOI in children and infants requiring tracheal intubation with a suspected difficult airway or who demonstrated a difficult airway which was unanticipated. Time to successful intubation, quality of imaging and ease of the intubation procedure were determined. RESULTS: A total of 26 patients (46% infants) were studied, and all successfully intubated at the first attempt using either the BF or FOI. Mouth opening was restricted in 38% of patients. Time required for intubation was shorter with the BF (52 ± 22 s) compared with the FOI (83 ± 24 s, P = 0.008). The image quality (excellent in 73% vs. 45%, P = 0.129) and the ease of the procedure (excellent in 67% vs. 18%, P = 0.015) were considered better with BF than with FOI. CONCLUSION: Although both the BF and FOI are suitable devices for the intubation of infants and children with difficult airways, the BF may allow faster tracheal intubation with a better image quality and ease of use.

A randomized controlled comparison of the Bonfils fiberscope and the GlideScope Cobalt AVL video laryngoscope for visualization of the larynx and intubation of the trachea in infants and small children with normal airways.

BACKGROUND: The Bonfils fiberscope (BF) used without the assistance of a laryngoscope failed to improve the view of direct laryngoscopy in children with normal airways. We hypothesized that if BF is supported by a laryngoscope--as recommended by its inventor--it can provide comparably good visualization of the glottis as the GlideScope(®) Cobalt AVL video laryngoscope (GS). METHODS: We included 100 children with normal airways in a randomized controlled trial. The study consisted of assessing the airway by direct laryngoscopy (DL), followed by intubation using either the BF or the GlideScope. Main outcome measures were the quality of visualization of the larynx by the percentage of glottis opening seen (POGO) and the time needed for intubation of the trachea. RESULTS: Visualization of the larynx (POGO) using the BF was significantly better than with DL (P = 0.016) or with GS (P = 0.001). The DL provided an allover better visualization than GS, although this difference was not significant and solely attributable to children weighing <15 kg. Intubation was successful in all cases with both devices. The time needed for intubation was shorter using the BF (36 ± 8 s) than with the GlideScope (49 ± 12 s, P < 0.001). CONCLUSION: The Bonfils fiberscope significantly improved the view on the larynx compared with direct laryngoscopy and the GlideScope and enables shorter intubation time than with the GlideScope.

Medication errors in pediatric emergencies: a systematic analysis.

BACKGROUND: Errors in drug administration are among the commonest medical errors. Children are particularly at risk for such errors because of the need to calculate doses individually. Doses that are ten times the correct amount (1000% of the correct dose) are occasionally given and can be life-threatening. In a simulated resuscitation in a pediatric emergency room, an error of this type occurred for one of the 32 medications that were ordered. The highest error rates are to be expected in prehospital emergency medicine. In this review, we analyze the process of ordering medications and describe the potential interventions for lowering error rates that have been evaluated to date. METHOD: Systematic literature review RESULTS: We found 32 original publications that concerned the evaluation of interventions for lowering error rates in the ordering of medications for children. Error rates can be lowered by interventions that improve prescribers' knowledge of pediatric pharmacotherapy (courses, immediately accessible sources of information) and by aids to the cognitive process of ordering medication (calculators, computer programs, tables of doses by weight). They can also be lowered by raising awareness of the problem of erroneous medication ordering and by monitoring medication orders, as well as by structured communication and standardized, unambiguously labeled drug preparations. In the hospital setting, computer programs for medication orders with a built-in pediatric pharmacological database are highly recommended. In the prehospital setting, the "pediatric emergency ruler" enables accurate estimation of the patient's weight, provides age-appropriate dosage recommendations, and directly indicates the steps needed for calculation of the correct dose. CONCLUSION: Children in medical emergency situations are at significant risk for medication errors. The measures described here can markedly lower the rate of dangerous errors.

[Difficult airway management in paediatric patients]. / Der schwierige Atemweg--Anästhesiologische Versorgung von Kindern.

A difficult airway in childhood is very uncommon. Therefore, it will always be an unfamiliar and menacing situation for most anaesthetists. Knowledge of the individual pathology, associated anaesthesiological problems and possible solutions provide the basis for successful airway management. Endoscopical techniques are essential for the process. The following article shows how a difficult airway in childhood can be recognized and which anaesthesiological options exist to handle such a situation.