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

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

Preoperative Predictors of Severe Respiratory Events After Tonsillectomy: Consideration for Pediatric Intensive Care Admission.

OBJECTIVE: Few data are available to guide postadenotonsillectomy (AT) pediatric intensive care (PICU) admission. The aim of this study of children with a preoperative polysomnogram (PSG) was to assess whether preoperative information may predict severe respiratory events (SRE) after AT. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary center. METHODS: Children aged 6 months to 17 years who underwent AT with preoperative polysomnography (2012-2018) were identified by billing codes. Data were extracted from medical records. SRE were defined as any 1 or more of desaturations <80% requiring intervention; newly initiated positive airway pressure; postoperative intubation; pneumonia/pneumonitis; respiratory code, cardiac arrest, or death. We hypothesized that SRE would be associated with age <24 months, major medical comorbidity, obesity (>95th percentile), apnea-hypopnea index (AHI) ≥ 30, and O2 nadir <70% on PSG. Analysis was performed with multivariable logistic regression. RESULTS: Of 1774 subjects, 28 (1.7%) experienced SRE. Compared to those without, children with SRE were on average younger (3 vs 5 years, p < .01) with a greater probability of medical comorbidities (59% vs 18%, p < .001). After adjustment for sex, black race, obesity, and age <24 months, children with major medical comorbidity were more likely than other children to have SRE (odds ratio [OR]: 14.2; 95% confidence interval [CI]: [5.7, 35.2]), as were children with AHI ≥ 30 (OR: 7.7 [3.0, 19.9]), or O2 nadir <70% (OR 6.1 [2.1, 17.9]). Age, obesity, sex, and black race did not independently predict SRE. CONCLUSION: PICU admission may be most prudent for children with complex medical co-morbidities, high AHI (>30), and/or low O2 nadir (<70%).

Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database.

BACKGROUND: Previous studies examining removal of endotracheal tubes and supraglottic devices under deep anesthesia were underpowered to identify rare complications. This study sought to report all adverse events associated with this practice found in a large national database of pediatric anesthesia adverse events. METHODS: An extract of an adverse events database created by the Wake Up Safe database, a multi-institutional pediatric anesthesia quality improvement initiative, was performed for this study. It was screened to identify anesthetics with variables indicating removal of airway devices under deep anesthesia. Three anesthesiologists screened the data to identify events where this practice possibly contributed to the event. Event data was extracted and collated. RESULTS: One hundred two events met screening criteria and 66 met inclusion criteria. Two cardiac etiology events were identified, one of which resulted in the patient's demise. The remaining 97% of events were respiratory in nature (64 events), including airway obstruction, laryngospasm, bronchospasm and aspiration. Some respiratory events consisted of multiple distinct events in series. Nineteen respiratory events resulted in cardiac arrest (29.7%) of which 15 (78.9%) were deemed preventable by local anesthesiologists performing independent review. Respiratory events resulted in intensive care unit admission (37.5%), prolonged intubation and temporary neurologic injury but no permanent harm. Provider and patient factors were root causes in most events. Upon investigation, areas for improvement identified included improving patient selection, ensuring monitoring, availability of intravenous access, and access to emergency drugs and equipment until emergence. CONCLUSIONS: Serious adverse events have been associated with this practice, but no respiratory events were associated with long-term harm.

Anesthesiologist-related factors associated with risk-adjusted pediatric anesthesia-related cardiopulmonary arrest: a retrospective two level analysis.

BACKGROUND: Pediatric anesthesia-related cardiac arrest is an uncommon but catastrophic adverse event which has been, in a previous study, associated with anesthesiologist-related factors such as number of days per year providing pediatric anesthesia. We aimed to replicate this and assess other anesthesiologist-related risk factors for anesthesia-related cardiac arrest after adjusting for known underlying risk factors present in the case mix. METHODS: We analyzed a large retrospectively collected patient cohort of anesthetics administered from 2006 to 2016 to children at a tertiary pediatric hospital. Three reviewers independently reviewed cardiac arrests and categorized whether they appeared to be related to anesthesia care. Anesthesiologist-related factors including academic rank, experience, recent case mix, and days per year delivering pediatric anesthesia were assessed for association with anesthesia-related cardiac arrest after adjustment for underlying case mix. RESULTS: Cardiac arrest occurred in 240 of 109 775 anesthetics (incidence 22/10 000 anesthetics); 82 (7/10 000 anesthetics) were classified as anesthesia-related. In univariable analyses, anesthesia-related cardiac arrest was associated with age, (infants ≤180 days, p < .001) American Society of Anesthesiologists Physical Status, (>2, p < .001) American Society of Anesthesiologists Physical Status Emergency, (p = .0035) cardiac surgery, (p < .001) operating room location, (p = .0066) and resident/fellow supervision, (p = .009) but none of the anesthesiologist factors. Even after adjusting for age and American Society of Anesthesiologist Status, none of the anesthesiologist factors were associated with anesthesia-related cardiac arrest. CONCLUSIONS: Case mix explained all associations between higher risk of pediatric anesthesia-related cardiac arrest and anesthesiologist-related variables at our institution.

Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review.

Intrahospital transport of a critically ill patient is often required to achieve a diagnostic and/or therapeutic objective. However, clinicians who recommend a procedure that requires transport are often not fully aware of the risks of transport. Clinicians involved in the care of critically ill children may therefore benefit from a clear enumeration of adverse events that have occurred during transport, risk factors for those events, and guidance for event prevention. The objective of this review was to collect all published harm and adverse events that occurred in critically ill children in the context of transport within a medical center, as well as the incidence of each type of event. A secondary objective was to identify what interventions have been previously studied that reduce events and to collect recommendations for harm prevention from study authors. Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and CINAHL were searched in January 2018 and again in December 2018. Terms indicating pediatric patients, intrahospital transport, critical illness, and adverse events were used. Titles and abstracts were screened and full text was reviewed for any article meeting inclusion criteria. If articles included both children and adults, incidence data were collected only if the number of pediatric patients could be ascertained. Of 471 full-text articles reviewed, 40 met inclusion criteria, of which 24 included only children, totaling 4104 patient transports. Heterogeneity was high, owing to a wide range of populations, settings, data collection methods, and outcomes. The incidence of adverse events varied widely between studies. Examples of harm included emergent tracheostomy, pneumothorax, and cardiac arrest requiring chest compressions. Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. One transport-associated death was reported. When causation was assessed, most events were judged to have been preventable or potentially mitigated by improved double-checks and usage of checklists. Prospective studies demonstrated the superiority of mechanical ventilation over manual ventilation for intubated patients. Risk of adverse events during critical care transport appears to relate to the patient's underlying illness and degree of respiratory support. Recommendations for reducing these adverse events have frequently included the use of checklists. Other recommendations include optimization of the patient's physiological status before transport, training with transport equipment, double-checking of equipment before transport, and having experienced clinicians accompany the patient. All available recommendations for reducing transport-associated adverse events in included articles were collated and included.

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.

Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database.

BACKGROUND: Transporting patients under anesthesia care incurs numerous potential risks, especially for those with critical illness. The purpose of this study is to identify and report all pediatric anesthesia transport-associated adverse events from a preexisting database of perioperative adverse events. METHODS: An extract of the Wake Up Safe database was obtained on December 14, 2017, and screened for anesthesia transport-associated complications. This was defined as events occurring during or immediately after transport or movement of a pediatric patient during or in proximity to their care by anesthesiologists, including repositioning and transfer to recovery or an inpatient unit, if the cause was noted to be associated with anesthesia or handover. Events were excluded if the narrative clearly states that an event was ongoing and not impacted by anesthesia transport, such as a patient who develops cardiac arrest that then requires emergent transfer to the operating room. The search methodology included specific existing data elements that indicate transport of the patient, handover or intensive care status preoperatively as well as a free-text search of the narrative for fragments of words indicating movement. Screened events were reviewed by 3 anesthesiologists for inclusion, and all data elements were extracted for analysis. RESULTS: Of 2971 events in the database extract, 63.8% met screening criteria and 5.0% (148 events) were related to transport. Events were primarily respiratory in nature. Nearly 40% of all reported events occurred in infants age ≤6 months. A total of 59.7% of events were at least somewhat preventable and 36.4% were associated with patient harm, usually temporary. Of the 86 reported cardiac arrests, 50 (58.1%) had respiratory causes, of which 74% related to anesthesia or perioperative team factors. Respiratory events occurred at all stages of care, with 21.4% during preoperative transport and 75.5% postoperatively. Ninety-three percent of unplanned extubations occurred in patients 6 months and younger. Ten medication events were noted, 2 of which resulted in cardiac arrest. Root causes in all events related primarily to provider and patient factors, with occasional references to verbal miscommunication. CONCLUSIONS: Five percent of reported pediatric anesthesia adverse events are associated with transport. Learning points highlight the risk of emergence from anesthesia during transport to recovery or intensive care unit (ICU). ICU patients undergoing anesthesia transport face risks relating to transitions in providers, equipment, sedation, and physical positioning. Sedation and neuromuscular blockade may be necessary for transport in some patients but has been associated with adverse events in others.

Academic Anesthesiologists Perceive Significant Internal Barriers to Intraoperative Teaching in a Cross-Sectional Survey.

BACKGROUND: Academic anesthesiologists have numerous demands on their time, and this can erode teaching quality. Reducing barriers to teaching may ameliorate this. The primary aim of this study is to evaluate the learning environment and identify barriers to clinical teaching using a multicenter survey approach. METHODS: Anesthesiologists at four academic centers were surveyed to understand barriers to clinical teaching. Demographic data and time spent teaching were collected. Faculty attitudes regarding teaching, resident physician perceptions of their teaching, supportiveness of departmental and operating room leadership, whether they enjoyed teaching, and the perceived quality of their own teaching ("self-efficacy") were assessed using Likert scales. Principal component analysis was performed to identify themes in these data. Pearson correlation, t test, and linear regression analyses were used to evaluate interactions between themes. RESULTS: The response rate was 40.6% (230/566). Responding faculty expressed a high level of engagement with the teaching role. Clinical production pressure was a common theme. Faculty who spent more time teaching reported greater enjoyment of teaching, feeling better about their teaching, and were better prepared to teach. Enjoyment of teaching was not independently associated with more time spent teaching. Regression analysis revealed that perceptions of environmental factors (including production pressure) had no independent effect on time spent teaching or on self-efficacy in teaching quality. Faculty self-efficacy was positively related to enjoyment of teaching as well as making teaching a higher priority. CONCLUSIONS: Improving perceptions of the learning environment might be best achieved by mitigating production pressure and improving faculty self-efficacy in their teaching.