Reducing Intraoperative Hypothermia in Infants from the Neonatal Intensive Care Unit.

Infants from the neonatal intensive care unit (NICU) undergoing surgery in the operating room (OR) are at greater risk for hypothermia during surgery than afterward due to environmental heat loss, anesthesia, and inconsistent temperature monitoring. A multidisciplinary team aimed to reduce hypothermia (<36.1 °C) for infants at a level IV NICU at the beginning of the operation (first OR temperature) or at any time during the operation (lowest OR temperature) by 25%. Methods: The team followed preoperative, intraoperative (first, lowest, and last OR), and postoperative temperatures. It sought to reduce intraoperative hypothermia using the "Model for Improvement" by standardizing temperature monitoring, transport, and OR warming, including raising ambient OR temperatures to 74°F. Temperature monitoring was continuous, secure, and automated. The balancing metric was postoperative hyperthermia (>38 °C). Results: Over 4 years, there were 1235 operations: 455 in the baseline and 780 in the intervention period. The percentage of infants experiencing hypothermia upon OR arrival and at any point during the operation decreased from 48.7% to 6.4% and 67.5% to 37.4%, respectively. Upon return to the NICU, the percentage of infants experiencing postoperative hypothermia decreased from 5.8% to 2.1%, while postoperative hyperthermia increased from 0.8% to 2.6%. Conclusions: Intraoperative hypothermia is more prevalent than postoperative hypothermia. Standardizing temperature monitoring, transport, and OR warming reduces both; however, further reduction requires a better understanding of how and when risk factors contribute to hypothermia to avoid further increasing hyperthermia. Continuous, secure, and automated data collection improved temperature management by enhancing situational awareness and facilitating data analysis.

Error traps in pediatric difficult airway management.

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.

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach.

OBJECTIVE: Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN: Quality improvement initiative. METHODS: Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS: In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS: Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:S1-S10, 2021.

The Development and Piloting of a Digital Checklist to Increase Access and Usage of Campus Online Sexual Violence Resources.

As colleges seek to respond to campus sexual assault, administrators are making policies, programs, and resources related to sexual violence available to students and members of the school community online. Keeping this content current and accessible can be challenging in the context of rapidly changing information and competing priorities across campuses. In response to this challenge, we developed a free, online protocol for campus leaders to quickly assess gaps in their online sexual violence resources. The "Digital Checklist" delineates action steps that campus administrators can take to determine whether information related to campus sexual assault is easily located, current, relevant, and accessible. We found that while schools made an effort to increase the availability of information online, the checklist helped identify gaps that, if remedied, would allow more students to access that information. The overall goal for the checklist is to provide schools with actionable, real-time, and trackable data regarding the utility and accessibility of online sexual violence information and resources and to complement other campus sexual assault prevention and intervention efforts.

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. RESULTS: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. CONCLUSIONS: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

An update on newer pediatric supraglottic airways with recommendations for clinical use.

Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

A randomized comparison between the i-gel™ and the air-Q™ supraglottic airways when used by anesthesiology trainees as conduits for tracheal intubation in children.

PURPOSE: Supraglottic airways are commonly used as conduits for fibreoptic bronchoscopy (FOB)-guided intubation in pediatric patients. We hypothesized that anesthesiology trainees with limited prior experience with FOB-guided intubation through a supraglottic airway in children would intubate the trachea faster through the air-Q™ supraglottic airway than through the i-gel™. METHODS: Ninety-six children aged one month to six years were randomized to receive either the i-gel or air-Q for FOB-guided tracheal intubation by anesthesiology trainees. Time for successful tracheal intubation was the primary endpoint. Secondary endpoints included: time for device insertion, number of attempts for successful device insertion, airway leak pressures, FOB grade of laryngeal view, total number of attempts for tracheal intubation, time for removal of the device after tracheal intubation, and associated complications. RESULTS: The median (interquartile range [IQR]) times to successful tracheal intubation for the air-Q (62.5 [47.9-77] sec) and the i-gel (55.9 [48.5-81.8] sec) were not significantly different (median difference 6.6 sec; 95% confidence interval [CI] -13.3 to 8.7; P = 0.53). The median (IQR) time to insertion for the air-Q (16.7 [14.4-20.0] sec) was shorter than for the i-gel (19.6 [16.7-23.0] sec) (median difference 2.9 sec; 95% CI 0.8 to 4.7; P = 0.005). There were no differences between devices with respect to airway leak pressures, success rates, and time to removal. Compared with the air-Q, the i-gel was associated with more problems during device removal after tracheal intubation, including breakage of the tracheal tube pilot balloon (n = 0 vs n = 13, respectively; P < 0.001), inadvertent extubation (n = 1 vs n = 5, respectively; P < 0.001), and difficulty controlling the tracheal tube (n = 0 vs n = 21, respectively; P < 0.001). CONCLUSIONS: Contrary to our hypothesis, both the air-Q and i-gel supraglottic airways served as effective conduits for FOB-guided tracheal intubation in children when performed by trainees with limited prior experience. The i-gel, however, was associated with more problems during device removal following tracheal intubation. This study was registered at http://clinicaltrials.gov/show/NCT02189590 .

Airway management options in a prone achondroplastic dwarf with a difficult airway after unintentional tracheal extubation during a wake-up test for spinal fusion: to flip or not to flip?

PURPOSE: To present a case of unintentional tracheal extubation in a prone positioned patient with a known difficult airway. CLINICAL FEATURES: This case report describes the unintended tracheal extubation of an achondroplastic dwarf with kyphosis undergoing spinal fusion and instrumentation. The patient had a history of obstructive sleep apnea and a difficult airway requiring fibreoptic-guided tracheal intubation through an air-Q™ supraglottic airway device. Abrupt head movement during a wake-up test to evaluate lost motor-evoked potential signals resulted in dislodgement of the tracheal tube. Airway obstruction was evidenced by rapid oxygen desaturation and the absence of end-tidal capnography waveforms despite apparent chest excursions. An air-Q was used for successfully rescuing the airway and quickly re-establishing oxygenation and ventilation, which eliminated the need for emergent supine positioning for airway management. The air-Q was then used as a conduit for fibreoptic-guided tracheal intubation while the patient remained in the prone position. CONCLUSION: This case highlights some of the safety advantages of supraglottic airway devices for airway rescue and subsequent tracheal intubation even with the patient in the prone position. The use of an air-Q may have the advantages of not requiring an intubation introducer technique and allowing for direct tracheal intubation with an appropriately sized cuffed tracheal tube.

Values, animal symbolism, and human-animal relationships associated to two threatened felids in Mapuche and Chilean local narratives.

BACKGROUND: The Chilean temperate rainforest has been subjected to dramatic fragmentation for agriculture and forestry exploitation. Carnivore species are particularly affected by fragmentation and the resulting resource use conflicts with humans. This study aimed at understanding values and human-animal relationships with negatively perceived threatened carnivores through the disclosure of local stories and Mapuche traditional folktales. METHODS: Our mixed approach comprised the qualitative analysis of 112 stories on the kodkod cat (Leopardus guigna) and the puma (Puma concolor) collected by students (9-14 years) from 28 schools in the Araucania region within their family contexts, 10 qualitative in-depth interviews with indigenous Mapuche people, 35 traditional Mapuche legends, and the significance of naming found in ethnographic collections. RESULTS: We revealed a quasi-extinction of traditional tales in the current knowledge pool about pumas and kodkods, local anecdotes, however, were present in significant numbers. Values associated to both felids were manifold, ranging from negativistic to positive values. While pumas played an important role in people's spirituality, negative mythological connotations persisted in kodkod stories. Four prominent relationships were derived: (1) Both felids represent threats to livestock, pumas even to life, (2) both felids are symbols for upcoming negative events, (3) pumas are spiritual creatures, and (4) kodkods are threatened by humans. Recommendations are provided for stimulating new ways of perceiving unpopular and threatened carnivores among those who live in vicinity to them.

A randomized comparison of the laryngeal mask airway supreme™ and laryngeal mask airway unique™ in infants and children: does cuff pressure influence leak pressure?

BACKGROUND: The cuff pressure for optimal airway sealing with first-generation laryngeal mask airway has been shown to be 40 cm H(2)O in children. Currently, there are no data regarding the ideal intracuff pressure for the laryngeal mask airway Supreme (Supreme) in children. OBJECTIVES: To compare the clinical performance of the laryngeal mask airway supreme with the laryngeal mask airway unique in infants and children. MATERIALS AND METHODS: One hundred eighty children were assigned to receive either a Supreme or a laryngeal mask airway-U. We hypothesized higher airway leak pressure with the Supreme at both 40 cm H(2)O and 60 cm H(2)O, when compared with the laryngeal mask airway-U. Ease and time of insertion, insertion attempts, fiber optic examination, quality of airway, efficacy of mechanical ventilation, success of gastric tube placement (Supreme), incidence of gastric insufflation, and complications were also assessed. RESULTS: Airway leak pressure at an intracuff pressure of 60 cm H(2)O for the Supreme was 17.4 (5.2) vs laryngeal mask airway-U at 18.4 (6.6) cm H(2)O and did not differ when compared to an intracuff pressure of 40 cm H(2)O for both devices; Supreme at 17.2 (5) vs laryngeal mask airway-U at 17.7 (6) cm H(2)O. The laryngeal mask airway-U was associated with higher first-attempt success rates. The Supreme was associated with less gastric insufflation than the laryngeal mask airway-U. CONCLUSIONS: Intracuff pressures of 40 cm H(2)O may be sufficient for the Supreme in children, and there may be no added benefit of an intracuff pressure of 60 cm H(2)O, as leak pressures were similar. The Supreme may be preferred over the laryngeal mask airway-U for its lower rates of gastric insufflation and provision for gastric access when mechanical ventilation is utilized.

A randomized equivalence trial comparing the i-gel and laryngeal mask airway Supreme in children.

BACKGROUND: The laryngeal mask airway Supreme (Supreme) is a new single-use supraglottic device with gastric access capability now available in all sizes for children. OBJECTIVES: To compare the i-gel with the Supreme in children for routine airway maintenance. MATERIALS/METHODS: One hundred and seventy children, aged 3 months to 11 years, 5-50 kg in weight, were randomly assigned to receive either the i-gel or the Supreme. The primary outcome measured was airway leak pressure. Secondary outcomes included the following: ease and time for insertion, insertion success rate, fiberoptic grade of view, ease of gastric tube placement, number of airway manipulations, quality of airway during anesthetic maintenance, and complications. RESULTS: A total of 168 patients were assessed for the outcomes. The median (IQR [range]) airway leak pressure for the i-gel was higher than with the Supreme, 20 (18-25 [9-40]) cm H(2)O vs 17 (14-22 [10-40]) cm H(2)O, respectively (P = 0.001). There were no differences in the time for device insertion, fiberoptic grade of view, quality of airway, and complications. Median (IQR[range]) time of successful insertion of a gastric tube was faster with the Supreme, 12 (9.2-14.3 [5.2-44.2]) s than with the i-gel, 14 (11.9-19 [6.9-75]) s; P = 0.01. The number of airway manipulations during placement was higher with the i-gel than with the laryngeal mask airway Supreme (12 vs 13 patients), P = 0.02. CONCLUSIONS: In infants and children, when a single-use supraglottic device with gastric access capabilities is required, the i-gel demonstrated higher airway leak pressures and can be a useful alternative to the Supreme.

A randomized trial comparing the Ambu ® Aura-i ™ with the air-Q ™ intubating laryngeal airway as conduits for tracheal intubation in children.

OBJECTIVES: To assess the clinical performance of the Ambu Aura-i (Aura-i) in children. AIM: To compare the Aura-i with the air-Q intubating laryngeal airway (air-Q) for the purposes of fiberoptic-guided tracheal intubation. BACKGROUND: The Aura-i is a new supraglottic airway designed for tracheal intubation. MATERIALS/METHODS: One hundred twenty children, ages 1 month to 6 years, were randomized to receive either the Aura-i or air-Q, and divided into three equal subgroups (Group 1, 2, 3) based on weight. The time for successful tracheal intubation was primarily assessed. The ease, time, and number of attempts for successful device insertion, leak pressures, fiberoptic grade of laryngeal view, number of attempts time for removal of the device after tracheal intubation, and complications were secondarily assessed. RESULTS: Device placement, tracheal intubation, and removal after tracheal intubation were successful in all patients. There were no differences in the time to successful tracheal intubation through the Aura-i (32.9 ± 13.3 s), and the air-Q (33.9 ± 13 s; P = 0.68), or fiberoptic grade of view between devices. There was not a statistically significant correlation between the time to intubation and the fiberoptic grade of laryngeal view in any of the groups. There were no statistically significant differences in the overall leak pressures, air-Q (18.3 ± 6.1 cm H(2) O) vs Aura-i (16 ± 5.1 cm H(2) O; P = 0.05). In Group 1 (5-10 kg), leak pressures were higher with the air-Q (23.4 ± 7.2 cm H(2) O) than the Aura-i (16.1 ± 5.2 cm H(2) O; P = 0.001). There were no statistically significant differences in the time for removal between the two devices (P = 0.11). However, with the size 1.5 Aura-i, the pilot balloon of the tracheal tube was removed in order to facilitate the removal of the device after tracheal intubation. CONCLUSIONS: Both devices served as effective conduits for fiberoptic-guided tracheal intubation. The limitation of the narrower proximal airway tube of the size 1.5 Aura-i should be considered if cuffed tracheal tubes are to be utilized.

A cohort evaluation of the laryngeal mask airway-Supreme™ in children.

OBJECTIVES: To assess the clinical performance of the laryngeal mask airway-Supreme in children. AIM: The purpose of this prospective audit was to evaluate the feasibility of the laryngeal mask airway-Supreme in clinical practice and generate data for future comparison trials. BACKGROUND: The laryngeal mask airway-Supreme is a new second-generation supraglottic airway that was recently released in limited pediatric sizes (sizes 1, 2). METHODS: One hundred children, ASA I-III, newborn to 16 years of age, and undergoing various procedures requiring a size 1, 2, or 3 laryngeal mask airway-Supreme were studied. Assessments included insertion success rates, airway leak pressures, success of gastric tube insertion, quality of airway, and perioperative complications. RESULTS: The first-time insertion success rate was 97%, with an overall insertion success rate of 100%. The mean initial airway leak pressure for all patients was 22.3 ± 6.6 cm H(2) O. Gastric tube placement was possible in 98% of patients. Complications were noted in six patients: coughing or laryngospasm (n = 3), sore throat (n = 1), and dysphonia (n = 2). CONCLUSIONS: The laryngeal mask airway-Supreme was inserted with a high degree of success on the first attempt by clinicians with limited prior experience with the device. It was effectively used for a variety of procedures in children undergoing spontaneous and mechanical ventilation with minimal complications. The leak pressures demonstrated in this study, along with access for gastric decompression, suggest that the laryngeal mask airway-Supreme may be an effective device for positive pressure ventilation in children.

A randomized crossover comparison between the Laryngeal Mask Airway-Unique™ and the air-Q intubating laryngeal airway in children.

OBJECTIVES: The purpose of this randomized crossover study was to evaluate the feasibility of the air-Q intubating laryngeal airway (ILA) in clinical practice when compared with the Laryngeal Mask Airway-Unique(™) (LMA-U), the current standard of care for primary airway maintenance. AIM: We hypothesized that the ILA would have better airway seal pressures and laryngeal alignment than the LMA-U in anesthetized nonparalyzed children. BACKGROUND: The ILA is a newer supraglottic airway for children with design features that allow it to be used for primary airway maintenance and as a conduit for tracheal intubations. METHODS: Fifty healthy children, 6-36 months of age, 10-15 kg, who were scheduled for elective surgery in which the use of a size two LMA-U and size 1.5 ILA would be appropriate for airway maintenance, were enrolled into this randomized crossover study. Primary outcome measures were airway leak pressures and fiberoptic grades of view. Secondary outcome measures included ease and time for successful insertion, incidence of gastric insufflation, ventilation parameters, and complications. RESULTS: There were no statistically significant differences in regard to the ease of device insertion, time to ventilation, gastric insufflation, and ventilation parameters between the ILA and the LMA-U. All devices were successfully placed on the first attempt, and there were no instances of failure. There were statistically significant differences in the airway leak pressure between the ILA (19.0 ± 5.4 cmH(2)O) and the LMA-U (16.1 ± 4.9 cmH(2)O), P = 0.001. There were also statistically significant differences in the fiberoptic grades of view between the ILA and LMA-U, P = 0.004. CONCLUSIONS: The ILA had higher airway leak pressures and superior fiberoptic grades of view when compared with the LMA-U and can be a suitable alternative to the LMA-U in children weighing 10-15 kg.

Prospective evaluation of the self-pressurized air-Q intubating laryngeal airway in children.

OBJECTIVES: To assess the clinical efficacy of the self-pressurized air-Q ILA™ (ILA-SP). AIM: The purpose of this prospective audit was to evaluate the feasibility of the ILA-SP in clinical practice and generate data for future comparison trials. BACKGROUND: The ILA-SP is a new first-generation supraglottic airway for children with a self-adjusting cuff and lack of a pilot balloon. METHODS: Over a 4-month period, 352 children with an ASA physical status of I-III, newborn to 18 years of age, undergoing various procedures were studied. Data points assessed included insertion success rates, airway leak pressures, quality of ventilation, and perioperative complications associated with the use of this device. RESULTS: In 349 of the 352 patients in this study, the ILA-SP was used successfully as a primary supraglottic airway device in a variety of patients. Three patients required conversion to a standard laryngeal mask airway or a tracheal tube. The mean initial airway leak pressure for all patients was 17.8 ± 5.4 cm H(2)O, and 20.4 ± 5.5 cm H(2)O when re-checked at 10 min, which was statistically significant (P < 0.001). Complications were limited to 14 patients and related to reflex activation of the airway (coughing, laryngospasm, and bronchospasm) (n = 10), sore throat (n = 3), and blood staining on removal of the device (n = 1). There were no episodes of regurgitation, aspiration, or hoarseness. CONCLUSIONS: Acceptable clinical performance was demonstrated with the ILA-SP for a variety of procedures in infants and children with spontaneous and positive pressure ventilation. Future studies comparing this device to other supraglottic airways may provide useful information regarding the safety of the ILA-SP in pediatric clinical practice.

A clinical evaluation of the intubating laryngeal airway as a conduit for tracheal intubation in children.

BACKGROUND: The air-Q Intubating Laryngeal Airway (ILA) (Cookgas LLC, Mercury Medical, Clearwater, FL) is a supraglottic airway device available in pediatric sizes, with design features to facilitate passage of cuffed tracheal tubes when used to guide tracheal intubation. We designed this prospective observational study of the ILA to assess the ease of its placement in paralyzed pediatric patients, determine its position and alignment to the larynx using a fiberoptic bronchoscope, gauge its efficacy as a conduit for fiberoptic intubation with cuffed tracheal tubes, and evaluate the ability to remove the ILA without dislodgement of the tracheal tube after successful tracheal intubation. METHODS: One hundred healthy children, aged 6 months to 8 years, ASA physical status I to II, and scheduled for elective surgery requiring general endotracheal anesthesia were enrolled in this prospective study. Based on the manufacturer's guidelines, each patient received either a size 1.5 or 2.0 ILA according to their weight. The number of attempts for successful insertion, leak pressures, fiberoptic grade of view, number of attempts and time for tracheal intubation, time for ILA removal, and complications were recorded. RESULTS: ILA placement, fiberoptic tracheal intubation, and ILA removal were successful in all patients. The size 1.5 ILA cohort had significantly higher rates of epiglottic downfolding compared with the size 2.0 ILA cohort (P < 0.001), despite adequate ventilation variables. When comparing fiberoptic grade of view to weight, a moderate negative correlation was found (r = -0.41, P < 0.001), indicating that larger patients tended to have better fiberoptic grades of view. The size 1.5 ILA cohort had a significantly longer time to intubation (P = 0.04) compared with the size 2.0 ILA cohort. However, this difference may not be clinically significant because there was a large overlap of confidence bounds in the average times of the size 1.5 ILA (27.0 ± 13.0 seconds) and size 2.0 ILA cohorts (22.7 ± 6.9 seconds). When comparing weight to time to tracheal intubation, a weak correlation that was not statistically significant was found (r = -0.17, P = 0.09), showing that time to intubation did not differ significantly according to weight, despite higher fiberoptic grades in smaller patients. CONCLUSIONS: The ILA was easy to place and provided an effective conduit for tracheal intubation with cuffed tracheal tubes in children with normal airways. Additionally, removal of the ILA after successful intubation could be achieved quickly and without dislodgement of the tracheal tube. Because of the higher incidence of epiglottic downfolding in smaller patients, the use of fiberoptic bronchoscopy is recommended to assist with tracheal intubation through this device.

Retrospective audit of the air-Q intubating laryngeal airway as a conduit for tracheal intubation in pediatric patients with a difficult airway.

OBJECTIVES: To assess the efficacy of the ILA as a conduit for tracheal intubation in pediatric patients with a difficult airway. AIM: The primary goals of this retrospective audit were to assess the clinical performance of the ILA in pediatric patients with a difficult airway, expand on our initial favorable experience with this device, and collect pilot data for future prospective and comparison studies. METHODS: The charts of patients with a difficult airway in whom the ILA was used during a period of 1 year in a freestanding pediatric institution were reviewed following a practice change in the authors' institution favoring the ILA over the laryngeal mask airway as a conduit for tracheal intubation. RESULTS: Thirty-four pediatric patients had an ILA placed during the course of their airway management. Eight of the 34 patients in this cohort required emergent airway management. The median age was 47.1 (0.3-202.2) months and the median weight was 16.3 (3.9-86.0) kilograms. Three of the cases were unanticipated difficult airways and the remaining were anticipated difficult airways as a result of craniofacial syndromes (n = 21), cervical spine instability or immobility (n = 7), or airway hemorrhage (n = 3). Thirty-three of the 34 patients (97%) were intubated on the first attempt through the ILA, with the aid of a fiberoptic bronchoscope (n = 25), a Shikani Optical Stylet (n = 7), or blindly (n = 2). In one patient, blind tracheal intubation required a second attempt for successful intubation, making the overall success rate 100%. Oxygen desaturation was noted in 6 of the 34 cases. CONCLUSIONS: In a series of pediatric patients with difficult airways, the ILA was successfully used as a conduit for tracheal intubation in all patients. Visualization techniques may offer a greater degree of success in intubations through the ILA due to the potential for epiglottic down-folding in children.

The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series.

The air-Q intubating laryngeal airway (ILA) is a new supraglottic airway device which may overcome some limitations inherent to the classic laryngeal mask airway for tracheal intubation. We present a case series of patients with anticipated difficult airway in whom the air-Q ILA was successfully used as a conduit for fiberoptic intubation.