Efficacy of a hybrid technique of simultaneous videolaryngoscopy with flexible bronchoscopy in children with difficult direct laryngoscopy in the Pediatric Difficult Intubation Registry.

Children with difficult tracheal intubation are at increased risk of severe complications, including hypoxaemia and cardiac arrest. Increasing experience with the simultaneous use of videolaryngoscopy and flexible bronchoscopy (hybrid) in adults led us to hypothesise that this hybrid technique could be used safely and effectively in children under general anaesthesia. We reviewed observational data from the international Pediatric Difficult Intubation Registry from 2017 to 2021 to assess the safety and efficacy of hybrid tracheal intubation approaches in paediatric patients. In total, 140 patients who underwent 180 attempts at tracheal intubation with the hybrid technique were propensity score-matched 4:1 with 560 patients who underwent 800 attempts with a flexible bronchoscope. In the hybrid group, first attempt success was 70% (98/140) compared with 63% (352/560) in the flexible bronchoscope group (odds ratio (95%CI) 1.4 (0.9-2.1), p = 0.1). Eventual success rates in the matched groups were 90% (126/140) for hybrid vs. 89% (499/560) for flexible bronchoscope (1.1 (0.6-2.1), p = 0.8). Complication rates were similar in both groups (15% (28 complications in 182 attempts) hybrid; 13% (102 complications in 800 attempts) flexible bronchoscope, p = 0.3). The hybrid technique was more likely than flexible bronchoscopy to be used as a rescue technique following the failure of another technique (39% (55/140) vs. 25% (138/560), 2.1 (1.4-3.2) p < 0.001). While technically challenging, the hybrid technique has success rates similar to other advanced airway techniques, few complications and may be considered an alternative technique when developing an airway plan for paediatric patients whose tracheas are difficult to intubate under general anaesthesia.

Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia (GAS Study-A Prospective Randomized Trial).

BACKGROUND: The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension. METHODS: A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol. RESULTS: The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT). CONCLUSIONS: RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.

Use of deep laryngeal oxygen insufflation during laryngoscopy in children: a randomized clinical trial.

BACKGROUND: Brief periods of haemoglobin oxygen desaturation are common in children during induction of general anaesthesia. We tested the hypothesis that oxygen insufflation during intubation slows desaturation. METHODS: Patients 1-17 yr old undergoing nasotracheal intubation were enrolled and randomly assigned to one of three groups: standard direct laryngoscopy (DL); laryngoscopy with Truview PCD videolaryngoscope (VLO2); or laryngoscopy with an oxygen cannula attached to the side of a standard laryngoscope (DLO2). The co-primary outcomes were time to 1% reduction in [Formula: see text] from baseline, and the slope of overall desaturation vs time. All three groups were compared against each other. RESULTS: Data from 457 patients were available for the final analysis: 159 (35%) DL; 145 (32%) DLO2; and 153 (33%) VLO2. Both VLO2 and DLO2 were superior to DL in both time to a 1% reduction in [Formula: see text] from baseline and the overall rate of desaturation (all P<0.001). The 25th percentile (95% confidence interval) of time to a 1% saturation decrease was 30 (24, 39) s for DL, 67 (35, 149) s for DLO2 and 75 (37, 122) s for VLO2. Mean desaturation slope was 0.13 (0.11, 0.15)% s(-1) for DL, 0.04 (0.02, 0.06)% s(-1) for DLO2 and 0.03 (0.004, 0.05)% s(-1) for VLO2. We did not find a correlation between decrease in [Formula: see text] percentage and BMI or age. CONCLUSIONS: Laryngeal oxygen insufflation increases the time to 1% desaturation and reduces the overall rate of desaturation during laryngoscopy in children. CLINICAL TRIAL REGISTRATION: NCT01886807.

Peripheral nerve catheters in children: an analysis of safety and practice patterns from the pediatric regional anesthesia network (PRAN).

BACKGROUND: Peripheral nerve catheters (PNCs) are used with increasing frequency in children. Although adult studies have demonstrated safety with this technique, there have been few safety studies in children. The main objective of the current investigation was to examine the incidence of PNC complications in children undergoing surgery. METHODS: This is an observational, multi-institutional study using the Pediatric Regional Anesthesia Network (PRAN) database. Data pertaining to PNCs were entered prospectively into a secure, online database by each participating centre. Patient characteristics, anatomic location, localization techniques, medications used, and complications were recorded for each catheter. All complications and any sequelae were followed until resolution. RESULTS: There were 2074 PNCs included in the study. 251 adverse events and complications were recorded, resulting in an overall incidence (95% CI) of complications of 12.1% (10.7-13.5%). The most common complications were catheter malfunction, block failure, infection, and vascular puncture. There were no reports of persistent neurologic problems, serious infection, or local anaesthetic systemic toxicity, resulting in an estimated incidence (95% CI) of 0.04% (0.001-0.2%). Patients who developed an infection had used the catheters for a greater number of days, median (IQR) of 4.5 (3-7) days compared with 3 (1-3) days in the patients who did not develop an infection, P<0.0001. CONCLUSIONS: Our data support the safety of placing PNCs in children, with adverse event rates similar to adult studies. Catheter problems are common, yet minor, in severity.

An evaluation of the T-Line Tensymeter continuous noninvasive blood pressure device during induced hypotension.

A new continuous noninvasive blood pressure measurement device, the T-Line Tensymeter TL100 (Tensys Medical Inc., San Diego, CA, USA) which enables avoidance of arterial cannulation has been developed. We compared the values obtained using the T-Line values to simultaneous arterial line measurements in patients undergoing general anaesthesia with induced hypotension. Twenty-five patients, aged 18-70 years, were studied. The T-Line and arterial line were positioned on the contralateral wrists. Intra-operative, real-time, blood pressure data were electronically captured and stored on a computer. Bland-Altman plots and 95% limits of agreement show that the majority of T-Line data points were within 5 mmHg of the arterial line measurements (67%) and agreement was within 15 mmHg in 94.6% or more of all measurements. There was virtually no distinguishable error over the course of surgery using the device. In conclusion, the T-Line measurements correlate with arterial measurements during anaesthesia in which there were periods of both normotensive and hypotensive anaesthesia. The T-Line Tensymeter represents a noninvasive alternative to an arterial line in cases when arterial blood sampling is not required.

More or less CHAOS: case report and literature review suggesting the existence of a distinct subtype of congenital high airway obstruction syndrome.

Congenital obstruction of the upper airway (CHAOS) is a rare, usually lethal abnormality. A literature review of 36 prenatally diagnosed cases of CHAOS and the analysis of our own case suggest the existence of a distinct subtype of CHAOS, raising important implications for diagnosis and management. Serial fetal ultrasound examinations at 17-23 weeks' gestation showed hyperechoic and enlarged lungs, mediastinal shift, flattened diaphragm, polyhydramnios and apparently fluid-filled esophagus, findings interpreted as bilateral cystic adenomatoid malformation Type III. Ultrasound findings normalized around 32 weeks. The diagnosis of CHAOS was made after birth at term by direct laryngoscopy prompted by ventilatory difficulties and failed attempts at intubation. A pinhole opening posterior to the cricoid cartilage allowed the passage of an endotracheal tube. Based on observations in our case and those of five similar cases in the literature, we describe for the first time a subtype of CHAOS that is characterized by minor pharyngotracheal or laryngotracheal communications and associated with a less severe natural history and even resolution of ultrasound findings. In spite of this, a high index of awareness should be maintained because resolution of ultrasound findings does not necessarily indicate resolution of underlying pathology.

Use of a new supraglottic airway device--the CobraPLA--in a 'difficult to intubate/difficult to ventilate' scenario.

A 67-year-old male was scheduled for cadaveric renal transplant. Following rapid sequence anaesthesia, only the tip of the epiglottis was visualized. Mask ventilation was difficult, and therefore an alternative airway device was considered. A size 4 CobraPLA (Engineered Medical System, Indianapolis, IN) was inserted into the hypopharynx, and ventilation was easily accomplished. Then, a size 7 endotracheal tube was threaded over a fiberoptic bronchoscope, through the CobraPLA, into the trachea. The description and insertion technique of the CobraPLA, a new supraglottic airway device is shortly discussed. This is the first report of successful management of difficult mask ventilation with the new CobraPLA, supraglottic airway device.

Anesthesia for restrictive bariatric surgery (gastric bypass not included): laparoscopic vs open procedures.

UNLABELLED: Publications regarding anesthetic management for weight reduction surgery are scarce. We reviewed the records of 234 patients who underwent bariatric restrictive procedures (gastric bypass not included) from May 1999 to September 2000. Variables analyzed included demographics, anesthetic data and perioperative course. Patients were allocated into two groups: laparoscopic (LPG) and open procedures (OPG), comprising 167 and 67 patients respectively. Obstructive sleep apnea was present in 4.8% in LPG vs 6.1% in OPG. Awake fiberoptic intubation was performed in 3.6% in LPG and 1.5% in OPG. The other patients were anesthetized with rapid sequence induction (classic or modified). Grade III laryngoscopy was present in 6% in LPG and 7.1% in OPG. No intraoperative complications were encountered. Postoperative PACU follow-up time was similar. In both groups, i.v. meperidine was most frequently used for postoperative analgesia (in the PACU), as compared to the other analgesics employed (P<0.03). Early postoperative complications (prolonged mechanical ventilation, unplanned ICU admission, sepsis, re-operation) occurred more frequently in OPG, but the difference between the two groups was statistically insignificant (P<0.08). The length of hospitalization was 3.8+/-1.4 days in LPG and 6.2+/-6.6 in OPG (P<0.01). Mortality was zero. Anesthesia for restrictive bariatric surgery (both open and laparoscopic approaches) was associated with few complications. SUMMARY STATEMENT: We reviewed the records of 234 patients who underwent restrictive bariatric procedures (gastric bypass not included) from May 1999 to September 2000, in regard to perioperative complications. Anesthesia was associated with no intraoperative and few postoperative complications.

Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue.

In 50 morbidly obese patients, we quantified the soft tissue of the neck from the skin to the anterior aspect of the trachea at the vocal cords using ultrasound. Thyromental distance, mouth opening, limited neck mobility, modified Mallampati score, abnormal upper teeth, neck circumference and sleep apnoea were assessed as predictors of difficult laryngoscopy. Of the nine (18%) cases of difficult laryngoscopy, seven (78%) had a history of obstructive sleep apnoea, compared with two of the 41 patients (5%) in whom laryngoscopy was easy (p < 0.001). Patients in whom laryngoscopy was difficult had more pretracheal soft tissue (mean (SD) 28 (2.7) mm vs. 17.5 (1.8) mm; p < 0.001) and a greater neck circumference (50 (3.8) vs. 43.5 (2.2) cm; p < 0.001). None of the other predictors correlated with difficult laryngoscopy. We conclude that an abundance of pretracheal soft tissue at the level of the vocal cords is a good predictor of difficult laryngoscopy in obese patients.

[The significance and cost of preoperative laboratory screening in young healthy patients in a public hospital in Israel].

UNLABELLED: We evaluated the clinical significance and cost of routine preoperative laboratory screening in young healthy patients in a public hospital. Three hundred consecutive young (aged 18-40 years), healthy (ASA I) patients undergoing minor elective surgical procedures were enrolled in this prospective study. A preoperative test was considered to be significant if its result lead to a new diagnose or to cancellation of surgery. The lab tests revealed only one new diagnosis. None of the procedures were cancelled. The total cost of the lab tests was NIS 114,000. Of this amount, NIS 104,000 could have been saved if the tests were ordered as required by the patients medical history and physical examination and not performed routinely. CONCLUSION: This study suggests that routine preoperative laboratory screening is not recommended prior to minor, elective surgery in young, healthy patients.

A randomized multicenter study of remifentanil compared with halothane in neonates and infants undergoing pyloromyotomy. I. Emergence and recovery profiles.

UNLABELLED: Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after. IMPLICATIONS: The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.

A randomized multicenter study of remifentanil compared with halothane in neonates and infants undergoing pyloromyotomy. II. Perioperative breathing patterns in neonates and infants with pyloric stenosis.

UNLABELLED: Although former preterm birth infants are at risk for postoperative apnea after surgery, it is unclear whether the same is true of full-term birth infants. We evaluated the incidence of apnea in 60 full-term neonates and infants undergoing pyloromyotomy both before and after anesthesia. All subjects were randomized to a remifentanil- or halothane-based anesthetic. Apnea was defined by the presence of prolonged apnea (>15 s) or frequent brief apnea, as observed on the pneumocardiogram. Apnea occurred before surgery in 27% of subjects and after surgery in 16% of subjects, with no significant difference between subjects randomized to remifentanil or halothane anesthesia. This apnea was primarily central in origin, occurred throughout the recording epochs, and was associated with severe desaturation in some instances. Of the subjects with normal preoperative pneumocardiograms, new onset postoperative apnea occurred in 3 (23%) of 13 subjects who received halothane-based anesthetics versus 0 (0%) of 22 subjects who received remifentanil-based anesthetics (P = 0.04). Thus, postoperative apnea can follow anesthesia in otherwise healthy full-term infants after pyloromyotomy and is occasionally severe with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic. IMPLICATIONS: Abnormal breathing patterns can follow anesthesia in infants after surgical repair of pyloric stenosis. Occasionally, these patterns can be associated with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.

The incidence of class "zero" airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade.

IMPLICATIONS: In an earlier study we proposed the addition of a new airway class, zero (visualization of the epiglottis), to the four classes of the modified Mallampati classification. In this prospective study, 764 surgical patients were assessed with regard to their airway class (including class zero), laryngoscopy grade, and the effect of the airway class and other predictors on the laryngoscopy grade.

Body morphology and the speed of cutaneous rewarming.

BACKGROUND: Infants and children cool quickly because their surface area (and therefore heat loss) is large compared with their metabolic rate, which is mostly a function of body mass. Rewarming rate is a function of cutaneous heat transfer plus metabolic heat production divided by body mass. Therefore, the authors tested the hypothesis that the rate of forced-air rewarming is inversely related to body size. METHODS: Isoflurane, nitrous oxide, and fentanyl anesthesia were administered to infants, children, and adults scheduled to undergo hypothermic neurosurgery. All fluids were warmed to 37 degrees C and ambient temperature was maintained near 21 degrees C. Patients were covered with a full-body, forced-air cover of the appropriate size. The heater was set to low or ambient temperature to reduce core temperature to 34 degrees C in time for dural opening. Blower temperature was then adjusted to maintain core temperature at 34 degrees C for 1 h. Subsequently, the forced-air heater temperature was set to high (approximately 43 degrees C). Rewarming continued for the duration of surgery and postoperatively until core temperature exceeded 36.5 degrees C. The rewarming rate in individual patients was determined by linear regression. RESULTS: Rewarming rates were highly linear over time, with correlations coefficients (r2) averaging 0.98+/-0.02. There was a linear relation between rewarming rate (degrees C/h) and body surface area (BSA; m2): Rate (degrees C/h) = -0.59 x BSA (m2) + 1.9, r2 = 0.74. Halving BSA thus nearly doubled the rewarming rate. CONCLUSIONS: Infants and children rewarm two to three times faster than adults, thus rapidly recovering from accidental or therapeutic hypothermia.

Use of a ventilating tube exchanger in patients undergoing tracheostomy: report of two cases.

Two case reports in which a ventilating tube exchanger was used during tracheostomy in patients with potential for difficult reintubation are presented. We recommend leaving the ventilating tube exchanger in place for 48 hours to allow reintubation from above in the event of inadvertent decannulation in cases where difficult intubation is anticipated. Ventilating tube exchangers have been used to assist in the management of difficult airways in a variety of ways. These methods include the use of ventilating tube exchangers as malleable stylets, endotracheal tube exchangers and conduits through which oxygen can be delivered. We present two cases in which a ventilating tube exchanger was used as an adjunct to airway management in a novel fashion.

Sonoclot analysis in healthy children.

UNLABELLED: Although use of the Sonoclot device (Sienco, Inc., Morrison, CO) has been reported in isolated pediatric cases and in small reports in neonates, there are no published data for normal pediatric patients. As the device is used in situations of abnormal coagulation, such as cardiac and liver transplantation surgery, our aim was to determine normal data ranges in healthy pediatric surgical patients. Blood was withdrawn after anesthetic induction, and the Sonoclot activated clotting time, rate of clot formation, time to peak amplitude, and peak amplitude was compared among four pediatric groups (< 12 mo, 13-24 mo, 25-48 mo, 49 mo-9 yr) and an adult group. The Sonoclot activated clotting time in the < 12-mo and the Adult groups were shorter than the oldest group of children (P < 0.05), although all were within the anticipated normal range, and there were no significant differences in clot rate, peak amplitude, and time to peak amplitude among groups without apparent trends with increasing age. These Sonoclot variables quantify adequate global clot formation in pediatric patients and will facilitate clinical coagulation management with appropriate pediatric normal ranges, avoiding the application of extrapolated adult data to children. IMPLICATIONS: Sonoclot variables are presented for 95 healthy pediatric surgical patients in four age groups, with small differences found in the Sonoclot (Sienco, Inc., Morrison, CO) activated clotting time between two groups and no significant differences in three other variables among groups.

Celite-activated thrombelastography in children.

STUDY OBJECTIVE: To quantify global coagulation and establish normal ranges for the celite-activated thrombelastograph (TEG) in healthy pediatric patients. DESIGN: Prospective observational study. SETTING: Operating suite of a university-based hospital. PATIENTS: 110 healthy pediatric patients in four age groups and 25 healthy adult patients. INTERVENTIONS: Blood sampling for the celite-activated TEG was carried out after anesthetic induction. MEASUREMENTS: TEG indices: R time (reflecting time to fibrin formation), K time and alpha angle (fibrinogen-platelet interaction), maximum amplitude (reflecting maximal clot strength, platelet and fibrinogen function), TEG index (mathematical incorporation of the prior four measurements), and percent fibrinolysis at 30 minutes, were all recorded. MAIN RESULTS: Statistically significant differences between <12-month group in angle (compared to 25-48 month group) and % fibrinolysis (compared to all other pediatric groups). Significant differences in angle between two pediatric groups and adult group, and in the TEG index between three pediatric groups and adult group (all differences p < 0.05). CONCLUSIONS: These data identify changes of small magnitude in three celite-TEG parameters in healthy children compared to adults, without implication of abnormal coagulation between groups. Changes do not seem to be consistently related to age and will be useful for clinicians using the TEG to monitor (ab) normal coagulation in pediatric patients.