Assessment of Common Criteria for Awake Extubation in Infants and Young Children.

BACKGROUND: Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. METHODS: This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. RESULTS: Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). CONCLUSIONS: Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.

An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients.

BACKGROUND: The need for 1-lung ventilation in school age, pediatric patients is uncommon and as a result there are relatively few devices available to facilitate lung isolation in this population. Furthermore, little is known about the efficacy and techniques of placement of the currently available devices. One of the newest devices available that may be appropriate in this age group is the EZ-Blocker. AIMS: We aimed to examine our initial experience with the EZ-Blocker to evaluate the performance of this device with respect to potential improvements in technique and patient selection going forward. METHODS: We performed a retrospective chart review of all pediatric patients who underwent 1-lung ventilation with an EZ-Blocker since the blocker became available at our institution. We recorded demographics, details of placement, intraoperative course, number of repositions, and any postoperative morbidity related to blocker placement or 1-lung ventilation. RESULTS: We were able to correctly place the EZ-Blocker and achieve lung isolation in 8 of 11 patients. There was a single episode of repositioning required during 1-lung ventilation with an EZ-Blocker. CONCLUSION: The EZ-Blocker was successful in providing lung isolation for a majority of our school age patients. Size constraints in children <6 years of age, excessive secretions, and distortions of tracheal anatomy seemed to be the greatest hindrances to successful placement and positioning of the device. Once correctly positioned, however, the EZ-Blocker may be more stable than the Arndt endobronchial blocker.