Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time.

Background: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation: In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding: None.

Acute Dystonic Reaction After Propofol Administration: A Pediatric Case Report.

We present a case of a 12-year-old female with a history of infantile spasms who developed a propofol-associated acute dystonic reaction after emergence from general anesthesia for foot surgery. Uniquely, the patient's postoperative symptoms of an acute dystonic reaction were refractory to standard treatment with anticholinergics but were successfully treated with corticosteroids. The absence of any dystonic symptoms following subsequent foot surgery under general anesthesia without propofol supported a propofol-associated etiology. This case may contribute to a better understanding of the underlying mechanisms of propofol-associated acute dystonic reactions and adds a possible new treatment option.

Non-Markov models of single-molecule dynamics from information-theoretical analysis of trajectories.

Whether single-molecule trajectories, observed experimentally or in molecular simulations, can be described using simple models such as biased diffusion is a subject of considerable debate. Memory effects and anomalous diffusion have been reported in a number of studies, but directly inferring such effects from trajectories, especially given limited temporal and/or spatial resolution, has been a challenge. Recently, we proposed that this can be achieved with information-theoretical analysis of trajectories, which is based on the general observation that non-Markov effects make trajectories more predictable and, thus, more "compressible" by lossless compression algorithms. Toy models where discrete molecular states evolve in time were shown to be amenable to such analysis, but its application to continuous trajectories presents a challenge: the trajectories need to be digitized first, and digitization itself introduces non-Markov effects that depend on the specifics of how trajectories are sampled. Here we develop a milestoning-based method for information-theoretical analysis of continuous trajectories and show its utility in application to Markov and non-Markov models and to trajectories obtained from molecular simulations.

Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry.

BACKGROUND: Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. METHODS: We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. RESULTS: The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. CONCLUSIONS: Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study.

BACKGROUND AND OBJECTIVE: Management of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation. DESIGN: Retrospective cohort study. SETTING: Tertiary Children's Hospital. PARTICIPANTS: 6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed. EXCLUSION CRITERIA: age > 18 years, endotracheal tube or tracheostomy in-situ. METHODS/INTERVENTIONS: Patients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets. RESULTS: Of the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without. CONCLUSION: Despite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.

Lessons from COVID-19: A reflection on the strengths and weakness of early consensus recommendations for pediatric difficult airway management during a respiratory viral pandemic using a modified Delphi method.

BACKGROUND: The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID-19 pandemic. METHODS: The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID-19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. RECOMMENDATIONS: In the setting of the COVID-19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. REFLECTION: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID-19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID-19. They would likely be important initial steps in the face of novel respiratory viral pathogens. CONCLUSIONS: The consensus process cannot and should not replace evidence-based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown.

Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy.

BACKGROUND: In patients presenting for pyloromyotomy, most practitioners prioritize rapid securement of the airway due to concern for aspiration. However, there is a lack of consensus and limited evidence on the choice between rapid sequence induction (RSI) and modified RSI (mRSI). METHODS: The medical records of all patients presenting for pyloromyotomy from May 2012 to December 2018 were reviewed. The risk of hypoxemia (peripheral oxygen saturation [Spo2], <90%) during induction was compared between RSI and mRSI cohorts for all patients identified as well as in the neonate subgroup by univariate and multivariable logistic regression analysis. Complications (aspiration, intensive care unit admission, bradycardia, postoperative stridor, and hypotension) and initial intubation success for both cohorts were also compared. RESULTS: A total of 296 patients were identified: 181 in the RSI and 115 in the mRSI cohorts. RSI was associated with significantly higher rates of hypoxemia than mRSI (RSI, 30% [23%-37%]; mRSI, 17% [10%-24%]; P = .016). In multivariable logistic regression analysis of all patients, the adjusted odds ratio (OR) of hypoxemia for RSI versus mRSI was 2.8 (95% confidence interval [CI], 1.5-5.3; P = .003) and the OR of hypoxemia for multiple versus a single intubation attempt was 11.4 (95% CI, 5.8-22.5; P < .001). In multivariable logistic regression analysis of neonatal subgroup, the OR of hypoxemia for RSI versus mRSI was 6.5 (95% CI, 2.0-22.2; P < .001) and the OR of hypoxemia for multiple intubation versus single intubation attempts was 18.1 (95% CI, 4.7-40; P < .001). There were no induction-related complications in either the RSI and mRSI cohorts, and the initial intubation success rate was identical for both cohorts (78%). CONCLUSIONS: In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.

A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry.

BACKGROUND: The design of a videolaryngoscope blade may affect its efficacy. We classified videolaryngoscope blades as standard and non-standard shapes to compare their efficacy performing tracheal intubation in children enrolled in the Paediatric Difficult Intubation Registry. METHODS: Cases entered in the Registry from March 2017 to January 2020 were analysed. We compared the success rates of initial and eventual tracheal intubation, complications, and technical difficulties between the two groups and by weight stratification. RESULTS: Videolaryngoscopy was used in 1313 patients. Standard and non-standard blades were used in 529 and 740 patients, respectively. Both types were used in 44 patients. In children weighing <5 kg, standard blades had significantly greater success than non-standard blades at initial (51% vs 26%, P=0.002) and eventual (81% vs 58%, P=0.002) attempts at tracheal intubation. In multivariable logistic regression analysis, standard blades had 3-fold greater odds of success at initial tracheal intubations compared with non-standard blades (adjusted odds ratio 3.0, 95% confidence interval): 1.32-6.86, P=0.0009). Standard blades had 2.6-fold greater odds of success at eventual tracheal intubation compared with non-standard blades in children weighing <5 kg (adjusted odds ratio 2.6, 95% confidence interval: 1.08-6.25, P=0.033). There was no significant difference found in children weighing ≥5 kg. CONCLUSIONS: In infants weighing <5 kg, videolaryngoscopy with standard blades was associated with a significantly greater success rate than videolaryngoscopy with non-standard blades. Videolaryngoscopy with a standard blade is a sensible choice for tracheal intubation in children who weigh <5 kg.

The synergistic effect of dexmedetomidine on propofol for paediatric deep sedation: A randomised trial.

BACKGROUND: Propofol and dexmedetomidine are used separately, and sometimes together, for paediatric deep sedation. Although their combination has been described in adults, the effect of dexmedetomidine as a potential synergist in children has not been studied before. OBJECTIVES: The primary objective was to compare the propofol requirements of children who receive propofol alone with those who receive it in combination with dexmedetomidine for deep sedation for upper and lower endoscopic gastrointestinal procedures. DESIGN: This was a prospective, open-label, randomised study comparing patients who received propofol alone (group P) with those who received dexmedetomidine and propofol (group DP). The depth of sedation was titrated to a target bispectral (BIS) index. SETTING: A Gastroenterology Procedure Unit at a single, tertiary care academic medical centre from April 2018 until December 2019. PATIENTS: Eligible patients were scheduled for upper endoscopy, lower endoscopy or both. A total of 39 patients were enrolled (20 DP) and (19 P). INTERVENTIONS: Patients in Group DP received dexmedetomidine 0.5 µg kg-1 administered over 1 min followed by an infusion of 0.15 µg kg-1 h-1. In both groups, intravenous propofol was given in bolus increments titrated to a BIS index of 40 to 50 and then a continuous infusion of propofol to maintain BIS at 40 to 50. MAIN OUTCOME MEASURES: The primary outcome measure was propofol requirement in each group. Secondary outcome measures were time to achieve the targeted sedation depth, time to achieve an Aldrete recovery score of 9, duration of sedation, mean BIS values, adverse events, 'PAED' scores and time to discharge from the postanaesthesia care unit (PACU). RESULTS: The median (range) total dose of propofol was 0.23 (0.10 to 0.50) mg kg-1 min-1 in group DP and 0.40 (0.20 to 0.50) mg kg-1 min-1 in group P (P = 0.0004). Time of discharge from the PACU was 60 (20 to 121) min in group DP and 63 (46 to 91) min in group P (P = 0.0409). CONCLUSION: The combination of dexmedetomidine and propofol for paediatric procedural sedation achieved a significant reduction in median propofol dose and a slightly shorter median time to discharge from PACU. Large-scale studies may determine whether this reduction decreases the risk of significant adverse events. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02952222.

Is Intensive Care Unit Admission Necessary After Removal of Mandibular Distraction Devices in Infants With Robin Sequence?

OBJECTIVE: Intensive care unit (ICU) care is routinely required after the operation to initiate mandibular distraction osteogenesis (MDO) in infants with Robin sequence (RS). Many patients are also managed in the ICU after subsequent device removal. It is uncertain if ICU care, which is expensive and limited, is necessary after this second operation. The objective of this study was to evaluate the incidence of respiratory events following device removal. We hypothesized that respiratory events would be infrequent and non-ICU inpatient monitoring would be adequate. DESIGN: This is a retrospective study of patients with RS from 2013 to 2018. PATIENTS: Patients were included if they had MDO and distractor removal during the first year of life. Patients were excluded if they had a tracheostomy or remained intubated after distractor removal. MAIN OUTCOME MEASURE: Postoperative respiratory events. RESULTS: Twenty-five (60% male) patients were included. Mean age and weight at distractor removal were 142 ± 79 days of life and 5.5 ± 1.1 kg. Mean apnea-hypopnea index after completion of distraction was 1.1 ± 1.5 events/hour. Two (8%) patients experienced postoperative respiratory events that required intervention. In 1 (4% of sample) of these, the event was deemed to have benefited from ICU-level care. Two variables were significantly associated with these events: congenital heart disease (P = .020) and concomitant procedure performed during the same operation (P = .020). CONCLUSIONS: Intensive care unit-level care is rarely needed after distractor removal in infants with RS. Intensive care unit admission should be considered in patients with congenital cardiac disease and when having multiple operations during the same anesthetic.

Airway Abnormalities in Patients With Congenital Heart Disease: Incidence and Associated Factors.

OBJECTIVES: Airway abnormalities complicate the perioperative course of patients with congenital heart disease (CHD), leading to significant morbidity and mortality. The literature describing airway abnormalities in those patients is scarce. This study aimed to determine the incidence of airway abnormalities in CHD patients and identify associated factors, genetic syndromes, and cardiac diagnoses. DESIGN: Retrospective study conducted after institutional review board approval. SETTING: Tertiary children's hospital. PARTICIPANTS: Patients presenting for cardiac diagnostic, interventional, or surgical procedures from 2012 to 2018. A total of 9,495 encounters were reviewed. EXCLUSION CRITERIA: age >18 years. Methods/Interventions: Age, weight, sex, intubation technique, number of intubation attempts, and difficult intubation (DI) were recorded. Using the International Classification of Diseases, Ninth and Tenth Revisions codes, genetic syndromes, acquired and congenital airway abnormalities, and cardiac diagnoses were identified. Multivariate generalized estimating equations modeling was used to identify independent predictors of airway abnormalities. RESULTS: A total of 4,797 patients, with 8,657 encounters were included. The median age was 1.3 years (interquartile range [IQR]: 0.2-6.0) and weight was 9.2 kg (IQR: 4.3-19.2), and 55% were male. A total of 16.7% had at least 1 genetic syndrome; 8.5% had congenital airway abnormalities and 9.7% acquired. Incidence of DI was 1.1%. The most common syndromes were Down, 22q11.2 microdeletion, and CHARGE. The most frequent congenital airway abnormalities were laryngomalacia and bronchomalacia, and the most frequent acquired were partial and total vocal cord paralysis. CONCLUSION: The likelihood of a coexistent airway abnormality should be considered in premature CHD patients, weight <10 kg, and in those with specific cardiac lesions and a concomitant genetic syndrome. Preoperative identification of patients at high risk of airway abnormalities is useful in planning their perioperative airway management.

Aerosol barriers in pediatric anesthesiology: Clinical data supports FDA caution.

BACKGROUND: The onset of the COVID19 pandemic drove the rapid development and adoption of physical barriers intended to protect providers from aerosols generated during airway management. We report our initial experience with aerosol barrier devices in pediatric patients and raise concerns that they may increase risk to patients. METHODS: In March 2020, we developed and implemented simulation training and use of plastic aerosol barrier devices as a component of our perioperative COVID-19 workflow. As part of our quality improvement process, we obtained detailed feedback via a web-based survey after cases were performed while using these aerosol barriers. RESULTS: Between March and June 2020, 36 pediatric patients age 1mo-18years with anatomically normal airways and either PCR confirmed or suspected COVID-19 were intubated under an aerosol barrier as part of urgent or emergent anesthetic care at our institution. Experienced providers had more difficulty than expected in six (16.7%) of the cases with four cases requiring multiple attempts to secure the airway and two cases involving pronounced difficulty in a single attempt. The aerosol barrier was perceived as a contributing factor to difficulty in all cases. CONCLUSION: The use of barriers may result in unanticipated difficulties with airway management, particularly in pediatric patients, which could lead to hypoxemia or other patient harm. Our initial experience in pediatric patients is the first such report in patients and provides clinical data which corroborates the simulation data prompting the FDA to withdraw support of barriers.

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.

The Use of Bispectral Index Monitoring Does Not Change Intraoperative Exposure to Volatile Anesthetics in Children.

The exposure of infants and children to volatile anesthetics, such as sevoflurane, has been a topic of concern with respect to the potential risk for long term neurocognitive effects. The primary objective of this study was to determine whether the perioperative utilization of Bispectral Index (BIS) monitoring alters the sevoflurane delivery and exposure to children. This is a prospective randomized trial of two groups of healthy ambulatory day surgery patients (2 to 12 years). The patients in both groups had the BIS applied soon after the induction of general anesthesia, but only the anesthesiologists in the group randomized to BIS visible were able to see the BIS values. All of the patients received general anesthesia with sevoflurane. This study found no difference in the overall exposure to sevoflurane between both groups (mean end-tidal sevoflurane level of 1.8 in both groups, P = 084). The duration of time in the recovery room, the time to meet discharge criteria, the Pediatric Agitation Emergence Delirium (PAED) scores and the Face, Legs, Activity, Cry, Consolability (FLACC) scores were not statistically different between the groups. The application and utilization of intraoperative BIS monitoring does not alter the sevoflurane administration nor the discharge readiness nor the recovery profile in healthy ambulatory children.