An analysis of a new rapid difficult airway response team in a vertically built children's hospital.

BACKGROUND: Intrahospital transport is associated with adverse events. This challenge is amplified during airway management. Although difficult airway response teams have been described, little attention has been paid to patient transport during difficult airway management versus the alternative of managing patient airways without moving the patient. This is especially needed in a 22-floor vertical hospital. HYPOTHESIS: Development of a rapid difficult airway response team and an associated difficult airway cart will allow for the ability to manage difficult airways in the patient's primary location. METHODS: A retrospective chart review of all rapid difficult airway response activations from December 18, 2019 to December 31, 2021 was performed to determine the number of airways secured in the patient's primary location (primary outcome). Secondary outcomes included length of time until airway securement, airway device used, number of attempts, complications, use of front of neck access, and mortality. RESULTS: There were 96 rapid difficult airway response activations in a 2-year period, with 18 activations deemed inappropriate. Of the 78 indicated rapid difficult airway response deployments, all activations resulted in a secure airway, and 76 (97.4%) of cases had an airway secured in the patient's primary location. The mean time to airway securement was 17.1 min (standard deviation 18.8 min). The most common methods of airway securement were direct laryngoscopy (42.3%, 33/78) and video laryngoscopy (29.5%, 23/78). The mean number of attempts by the rapid difficult airway response team was 1.4. There were no documented cases requiring front of neck access. The Cormack-Lehane airway grade at time of intubation was I-II in 83.3% (65/78) of activations. Rapid difficult airway response activation resulted in 16 cases of cardiac arrest and 4 patient deaths within 48 h. CONCLUSIONS: A rapid difficult airway response team allows a large majority of patients' airways to be managed and secured in the patient's primary hospital location. Future directions include reducing time to airway securement and identifying factors associated with cardiac arrest.

Ventilation through small-bore airways in children by implementing active expiration.

Management of narrowed airways can be challenging, especially in the smallest patients. This educational review focusses on active expiration through small-bore airways with the Ventrain (Ventinova Medical, Eindhoven, The Netherlands). Manual ventilation with the Ventrain establishes inspiratory and expiratory flow control: By setting an appropriate flow, the volume of gas insufflated over time can be controlled and expiration through a small-bore airway is expedited by jet-flow generated suction, coined "expiratory ventilation assistance" (EVA). This overcomes the inherent risks of emergency jet ventilation especially in pediatric airway emergencies. Active expiration by EVA has been clinically introduced to turn a "straw in the airway" into a lifesaver allowing not only for quick and reliable reoxygenation but also adequate ventilation. As well as managing airway emergencies, ventilating through small-bore airways by applying EVA implements new options for pediatric airway management in elective interventional procedures. Safe application of EVA demands a thorough understanding of the required equipment, the principle and function of the Ventrain, technical prerequisites, clinical safety measures, and, most importantly, appropriate training.

Patient and operative factors associated with unanticipated intensive care admission and outcomes following posterior fossa decompressions in children: A retrospective study.

INTRODUCTION: Posterior fossa decompression for Chiari I Malformation is a common pediatric neurosurgical procedure. We sought to identify the impact of anesthesia-related intraoperative complications on unanticipated admission to the intensive care unit and outcomes following posterior fossa decompression. METHODS: Medical records of all patients <18 years who underwent surgery for Chiari I malformation between 1/1/09 and 1/31/21 at the Ann & Robert H. Lurie Children's Hospital of Chicago were included. Records were reviewed for patient characteristics, anesthesia-related intraoperative complications, postoperative complications, and surgical outcomes. The primary outcome was the incidence of unanticipated admission to the intensive care unit, and the primary variable of interest was an anesthesia-related intraoperative complication. Patient, surgical characteristics, and year of surgery were also compared between patients with and without an unanticipated admission to the intensive care unit, and a multi-variable adjusted estimate of odds of unanticipated admission to the intensive care unit admission following an anesthesia-related intraoperative complication was performed. Secondary outcomes included anesthesia factors associated with an anesthesia-related intraoperative event, and postoperative complications and surgical outcomes between patients admitted to the intensive care unit and those who were not. RESULTS: Two hundred ninety-six patients with Chiari I Malformation were identified. Clinical characteristics associated with an unanticipated admission to the intensive care unit were younger age, American Society of Anesthesiologist (ASA) physical status >2 and an anesthesia-related intraoperative complication. 29 anesthesia-related intraoperative complications were observed in 25 patients (8.4%). Two of 25 patients (8%) with an anesthesia-related intraoperative complication compared with 3 of 271 (1%) patients without anesthesia-related intraoperative complication had an unanticipated admission to the intensive care unit, odds ratio 7.8 (95% CI 1.2-48.8, p = .010). When adjusted for age, sex, ASA physical status, presenting symptoms, concomitant syringomyelia, previous decompression surgery and year of surgery, the odds ratio for an unanticipated admission to the intensive care unit following an anesthesia-related intraoperative complication was 5.9 (95% CI 0.51-59.6, p = .149). There were no differences in surgical outcomes between patients with or without an unanticipated admission to the intensive care unit. CONCLUSION: Our study demonstrates that although anesthesia-related intraoperative complications during posterior fossa decompression are infrequent, they are associated with an increased risk of an unanticipated admission to the intensive care unit.

Difficult Airway Management in Adult Coronavirus Disease 2019 Patients: Statement by the Society of Airway Management.

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

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.

A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching.

BACKGROUND: Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial. The Pediatric Difficult Intubation (PeDI) Registry is an international multicenter registry that collects intubation data in difficult to intubate children. The registry captures the initial (at induction) and final ventilation technique (at intubation), the use of neuromuscular blocking drugs (NMBDs), airway reactivity during intubation, and complications. We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches. METHODS: We queried the PeDI Registry for cases entered between September 2012 and February 2016, from 16 children's hospitals. We categorized the attending anesthesiologist's ventilation plan into 3 groups: spontaneous ventilation, controlled ventilation after administering an NMBD, and controlled ventilation without administering an NMBD. Generalized Estimating Equation (GEE) model, with a binomial family distribution and logit link, was used to determine the association between ventilation technique and the risk of complications, as well as to account for within-site clustering. Propensity score matching was further applied to balance pretreatment characteristics of ventilation groups. RESULTS: Of 1289 anticipated difficult intubations, 507 (39%) were managed with spontaneous ventilation, 453 (35%) controlled ventilation with an NMBD, and 329 (26%) controlled ventilation without an NMBD. Complications occurred in 242 (18.8%; 95% confidence interval [CI], 16.6%-20.9%) patients. Of these, 218 (16.9%) were nonsevere, and 24 (1.9%) were severe. The spontaneous ventilation group had 114 (22.5%, standardized residual [Std.Res] = 4.29) nonsevere complications, which was higher than the controlled ventilation with an NMBD 60 (13.3%, Std.Res = -2.58), and controlled ventilation without an NMBD 44 (13.4%, Std.Res = -1.98), P < .001. Nearest neighbor matching with caliper width equal to 0.2 of the standard deviation (SD) of the logit of the propensity score also demonstrated that patients with spontaneous ventilation had greater odds of complications compared to controlled ventilation techniques: odds ratio (OR) = 2.07 (95% CI, 1.36-3.15; P = .001). CONCLUSIONS: Spontaneous ventilation is associated with more nonsevere complications, such as hypoxemia and laryngospasm, than controlled ventilation techniques during intubation of children with difficult airways. Inadequate anesthetic depth may contribute to increased complications.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

The design of the perfect pediatric supraglottic airway device.

The design evolution of the pediatric supraglottic airway device has experienced a long and productive journey. We have a wealth of clinical studies to support progress and advancements in pediatric clinical practice. While all of the  supraglottic airway devices have been used successfully in millions of children, it is important to be aware of design advantages and disadvantages of the different models of  supraglottic airway devices. Current pediatric supraglottic airway devices may be improved in design to be more ideal. Industry-changing technological advancements are likely to occur in the near future, which may further improve clinical performance of these devices.

Preoperative Pulmonary Function Test Results Are Not Associated With Postoperative Intubation in Children Undergoing Posterior Spinal Fusion for Scoliosis: A Retrospective Observational Study.

BACKGROUND: Preoperative pulmonary function tests are routinely obtained in children with scoliosis undergoing posterior spinal fusion despite unclear benefits as a perioperative risk assessment tool and frequent inability of patients to provide acceptable results. The goal of this study was to determine whether preoperative pulmonary function test results are associated with the need for postoperative intubation or intensive care unit admission after posterior spinal fusion. METHODS: The electronic medical records of patients who underwent posterior spinal fusion at a pediatric tertiary hospital between June 2012 and August 2017 were reviewed. Pulmonary function tests were consistently ordered for all patients, unless the patient was deemed unable to perform the test due to cognitive disability. Cases were categorized as primary or secondary scoliosis.Demographic data, preoperative bilevel positive airway pressure use, Cobb angle, intraoperative allogeneic blood transfusion, and ability to produce acceptable pulmonary function test results were collected for each patient. In patients with satisfactory pulmonary function test results, forced vital capacity and maximum inspiratory pressure were collected. Primary outcomes for analysis were postoperative intubation and intensive care unit admission. Univariable logistic regression models were used to assess the association between each variable of interest and the primary outcomes. RESULTS: The study sample included 433 patients, 288 with primary scoliosis and 145 with secondary scoliosis. Among patients with primary scoliosis, 90% were able to produce acceptable pulmonary function test results, zero remained intubated postoperatively, and 6 were admitted to the intensive care unit. Among patients with secondary scoliosis, 44% could not attempt pulmonary function tests. Among those who did attempt the test, 30% were unable to produce meaningful results. Forced vital capacity and maximum inspiratory pressure were not found to be associated with postoperative intubation or intensive care unit admission. Weight, Cobb angle, intraoperative blood transfusion, American Society of Anesthesiologists physical status classification, and preoperative bilevel positive airway pressure use were associated with patient outcomes. Among 357 total patients who attempted pulmonary function tests, 37 had high-risk results. Only 1 of these 37 patients remained intubated postoperatively. CONCLUSIONS: Patients undergoing posterior spinal fusion, especially those with secondary scoliosis, are frequently unable to adequately perform pulmonary function tests. Among patients with interpretable pulmonary function tests, there was no association between results and postoperative intubation or intensive care unit admission. Routine pulmonary function testing for all patients with scoliosis may not be indicated for purposes of risk assessment before posterior spinal fusion. Clinicians should consider a targeted approach and limit pulmonary function tests to patients for whom results may guide preoperative optimization as this may improve outcomes and reduce inefficiencies and costs.

Predictive factors for adverse outcomes in pediatric patients undergoing low-risk skin and soft tissue surgery: A database analysis of 6730 patients.

BACKGROUND: There is a paucity of data regarding risk stratification of pediatric patients presenting for low-risk skin and soft tissue surgery. AIMS: We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30-day readmission in a cohort of children undergoing low-risk skin and soft tissue surgery. METHODS: The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two-year period. The primary outcome was a 30-day postoperative complication composite. The secondary outcome was unplanned 30-day readmission. RESULTS: The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound-related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30-day readmission. CONCLUSION: Pediatric patients with American Society of Anesthesiologists classification ≥3 and nutritional deficiency undergoing low-risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30-day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications.

Pediatric Anesthesiology Fellows' Perception of Quality of Attending Supervision and Medical Errors.

BACKGROUND: Appropriate supervision has been shown to reduce medical errors in anesthesiology residents and other trainees across various specialties. Nonetheless, supervision of pediatric anesthesiology fellows has yet to be evaluated. The main objective of this survey investigation was to evaluate supervision of pediatric anesthesiology fellows in the United States. We hypothesized that there was an indirect association between perceived quality of faculty supervision of pediatric anesthesiology fellow trainees and the frequency of medical errors reported. METHODS: A survey of pediatric fellows from 53 pediatric anesthesiology fellowship programs in the United States was performed. The primary outcome was the frequency of self-reported errors by fellows, and the primary independent variable was supervision scores. Questions also assessed barriers for effective faculty supervision. RESULTS: One hundred seventy-six pediatric anesthesiology fellows were invited to participate, and 104 (59%) responded to the survey. Nine of 103 (9%, 95% confidence interval [CI], 4%-16%) respondents reported performing procedures, on >1 occasion, for which they were not properly trained for. Thirteen of 101 (13%, 95% CI, 7%-21%) reported making >1 mistake with negative consequence to patients, and 23 of 104 (22%, 95% CI, 15%-31%) reported >1 medication error in the last year. There were no differences in median (interquartile range) supervision scores between fellows who reported >1 medication error compared to those reporting ≤1 errors (3.4 [3.0-3.7] vs 3.4 [3.1-3.7]; median difference, 0; 99% CI, -0.3 to 0.3; P = .96). Similarly, there were no differences in those who reported >1 mistake with negative patient consequences, 3.3 (3.0-3.7), compared with those who did not report mistakes with negative patient consequences (3.4 [3.3-3.7]; median difference, 0.1; 99% CI, -0.2 to 0.6; P = .35). CONCLUSIONS: We detected a high rate of self-reported medication errors in pediatric anesthesiology fellows in the United States. Interestingly, fellows' perception of quality of faculty supervision was not associated with the frequency of reported errors. The current results with a narrow CI suggest the need to evaluate other potential factors that can be associated with the high frequency of reported errors by pediatric fellows (eg, fatigue, burnout). The identification of factors that lead to medical errors by pediatric anesthesiology fellows should be a main research priority to improve both trainee education and best practices of pediatric anesthesia.

Perioperative anesthetic management of children with congenital central hypoventilation syndrome and rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation.

BACKGROUND: Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation are rare neurocristopathies characterized by autonomic dysregulation including bradyarrhythmias, abnormal temperature control, and most significantly, abnormal control of breathing leading to tracheostomy and ventilator dependence as life support. Surgical advancements have made phrenic nerve-diaphragm pacemakers available, to eliminate the tether to a mechanical ventilator for 12-15 hours each day. The thoracoscopic approach to implantation has allowed for a less invasive approach which may have implications for pain control and recovery time. However, thoracoscopic implantation of these devices presents several challenges to the anesthesiologist in these complex ventilator-dependent patients, including, but not limited to, sequential lung isolation, prevention of hypothermia, and management of arrhythmias. Postoperative challenges may also include strategies to treat hemodynamic instability, managing the ventilator following lung derecruitment, and providing adequate pain control. AIMS: We aimed to describe the anesthetic management of Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation patients undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation and the nature and incidence of perioperative complications. METHODS: A retrospective chart review was performed of 14 children with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation undergoing phrenic nerve-diaphragm pacemaker implantation at a single academic pediatric hospital between 2009 and 2017. Demographic information, intraoperative management, and perioperative complications were analyzed from patient records. RESULTS: Twelve of 14 patients (86%) underwent an inhalational induction via tracheostomy. Lung isolation was achieved via fiberoptic guidance of a single lumen endotracheal tube sequentially into the right or left mainstem bronchi for 12 patients (86%). Double lumen endotracheal tubes were utilized in two patients (7%) and bronchial blockers in two patients (7%) for lung isolation. Anesthesia was maintained using a balanced technique of volatile agents (sevoflurane/isoflurane) and opioids (fentanyl). Bradyarrhythmias developed in six patients (43%) during surgery, 5 (36%) responded to anticholinergics and one patient (7%) required backup cardiac pacing using a previously implanted bipolar cardiac pacemaker. Intraoperative hypothermia (<35.5°C) was present in five patients (36%) despite the use of warming devices. Hypercarbia (>50 mm Hg) during lung isolation was present in eight patients (57%) and hemoglobin desaturation (<90%) in four patients (29%). Postoperatively, oxygen desaturation was a common complication with nine patients (64%) requiring supplemental oxygen administration via mechanical ventilator or manual bag ventilation. Opioids via patient-controlled analgesia devices (12 patients, 86%) or intermittent injection (two patients, 14%) were administered to all patients for postoperative pain control. Phrenic nerve-diaphragm pacemaker placement was successful thoracoscopically in all patients with no perioperative mortality. CONCLUSION: The main anesthetic challenges in patients with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation include hemodynamic instability, the propensity to develop hypothermia, hypercarbia/hypoxemia, and the need to perform bilateral sequential lung isolation requisite to the thoracoscopic implantation technique. Most anesthetic agents can be used safely in these patients; however, adequate knowledge of the susceptibility to complications, coupled with adequate preparation and understanding of the innate disease characteristics, are necessary to treat anticipated complications.

Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry.

BACKGROUND: The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. METHODS: Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. RESULTS: Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. CONCLUSIONS: In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

Unplanned, Postoperative Intubation in Pediatric Surgical Patients: Development and Validation of a Multivariable Prediction Model.

BACKGROUND: To date, the independent predictors and outcomes of unplanned postoperative intubation (UPI) in pediatric patients after noncardiac surgery are yet to be characterized. The authors aimed to identify the incidence and predictors of this event and evaluated the effect of this event on postoperative mortality. METHODS: Data of 87,920 patients from the American College of Surgeons National Surgical Quality Improvement Program Pediatric database were analyzed and assigned to derivation (n = 58,614; 66.7%) or validation (n = 29,306; 33.3%) cohorts. The derivation cohort was analyzed for the incidence and independent predictors of early UPI. The final multivariable logistic regression model was validated using the validation cohort. RESULTS: Early UPI occurred with an incidence of 0.2% in both cohorts. Among the 540 patients who experienced a UPI, 178 (33.0%) were intubated within the first 72 h after surgery. The final logistic regression model indicated operation time, severe cardiac risk factors, American Society of Anesthesiologists physical status classification more than or equal to 2, tumor involving the central nervous system, developmental delay/impaired cognitive function, past or current malignancy, and neonate status as independent predictors of early UPI. Having an early UPI was associated with an increased risk of unadjusted, all-cause 30-day mortality, demonstrating an odds ratio of 11.4 (95% CI, 5.8 to 22.4). CONCLUSIONS: Pediatric patients who experienced an early UPI after noncardiac surgery had an increased likelihood of unadjusted 30-day mortality by more than 11-fold. Identification of high-risk patients can allow for targeted intervention and potential prevention of such outcomes.

Tracheal extubation in children with difficult airways: a descriptive cohort analysis.

BACKGROUND: Tracheal extubation in children with difficult airways may be associated with an increased risk of perioperative adverse events. AIMS: The aim of this study was to describe the exubation techniques used/ success rates/ adverse events related to tracheal extubation practices in children with difficult airways. METHODS: A retrospective analysis of tracheal extubation practices in the difficult airway population over a 78-month period was performed. Difficult airway was defined as a Cormack and Lehane Grade 3 view or greater, and/or tracheal intubation requiring ≥ 3 attempts, and/or the need for an alternate device to direct laryngoscopy for successful tracheal intubation, and/or difficult mask ventilation. Reasons for difficult airway, demographic/surgical data, technique(s) for tracheal extubation, success/failure of tracheal extubation, and adverse events were recorded. A failed tracheal extubation was defined as any adverse event related to the airway occurring within 6 h of extubation requiring reintubation. RESULTS: A total of 519 patients were reported to have a difficult airway during this study period in a tertiary care pediatric center. Of these, 137 patients (26%) met inclusion criteria. Tracheal extubation was successfully performed in 130 patients (95%). The majority of tracheal exubations were performed without the use of additional airway adjuncts straight onto anesthesia face mask (121/137; 88%). Extubation failure occurred in seven cases (5%). Among the failed extubations, 6/7 children (85%) had evidence of severe upper airway obstruction and were <10 kg in weight. Of these children, one child required emergency tracheostomy, and two children (one with tracheal stenosis and other with spinal muscular atrophy) suffered from hypoxemic cardiac arrest and anoxic brain damage, respectively, and eventually died. CONCLUSIONS: In the studied population of children with difficult airways handled in a tertiary center environment, the majority of tracheal extubations could be performed without the use of airway adjuncts. In a minority of patients, tracheal extubation was associated with severe adverse outcomes.

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 .

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.