Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry

INTRODUCTION

Flexible bronchoscopy is the gold standard for difficult airway management. Clinicians are using videolaryngoscopy increasingly because it is perceived to be easier to use with high success rates. We conducted this study to compare the success rates of the two techniques when used after failed direct laryngoscopy in children with difficult tracheal intubations.

METHODS

We identified cases where initial attempts at direct laryngoscopy failed in the multicentre Pediatric Difficult Intubation Registry from August 2012-September 2023. After propensity score matching, we compared success rates and complications when videolaryngoscopy and flexible bronchoscopy were used as rescue techniques in the matched cohort and in matched patients weighing < 5 kg.

RESULTS

Clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy when direct laryngoscopy failed (64.7%, 1426/2281 vs. 7.3%, 156/2281, p < 0.001). Propensity score matched cohorts did not differ with respect to first-attempt success, eventual success and complications. For the subgroup of infants < 5 kg, clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy to rescue failed direct laryngoscopy (54.3%, 295/543 vs. 8.9%, 44/543, p < 0.001). First-attempt success was 43% (62/145) with videolaryngoscopy and 62% (18/29) with flexible bronchoscopy (odds ratio 2.19, 95%CI 0.96-4.98, p = 0.061). Eventual success was 71% (103/145) with videolaryngoscopy and 90% (26/29) with flexible bronchoscopy (odds ratio 3.53, 95%CI 1.03-12.2, p = 0.046). Complications did not differ between the techniques.

DISCUSSION

Videolaryngoscopy was chosen more frequently than flexible bronchoscopy as a rescue technique in a cohort of children with difficult direct laryngoscopy, with similar success and complication rates. For small infants, flexible bronchoscopy had a higher eventual success rate, underscoring the importance of maintaining proficiency with flexible bronchoscopy.

Availability and Practice Patterns of Videolaryngoscopy and Adaptation of Apneic Oxygenation in Pediatric Anesthesia: A Cross-Sectional Survey of Pediatric Anesthesiologists

BACKGROUND

Videolaryngoscopy (VL) and apneic oxygenation are highly recommended and increasingly used in pediatric anesthesia practice; yet, availability, use in recommended clinical settings (e.g., neonates, airway emergencies, and out-of-operating-room tracheal intubation), and the association of VL availability with how pediatric anesthesiologists define difficult intubation have not been explored.

METHOD

An electronic survey was distributed to the members of several international pediatric anesthesia societies to examine the availability and practice patterns of VL and to explore the criteria used to define a difficult tracheal intubation in children in the context of VL.

RESULTS

The response rate was 12.9%. VL was reported to be "most likely available" in main pediatric operating rooms and offsite locations 93% and 80.1% of the time, respectively. Fifty-seven percent of participants would select VL first when anticipating a difficult tracheal intubation; nearly 30% of respondents would choose direct laryngoscopy first and VL as a backup in this scenario. One-third of subjects would select VL as their first choice for nonoperating room (non-OR) emergency tracheal intubation and for premature or newborn infants, regardless of anticipated difficulty with intubation. Thirty percent of subjects reported using apneic oxygenation during difficult laryngoscopy. Institutional VL availability was not associated with how providers defined difficult tracheal intubation.

CONCLUSION

VL is highly available, but the adoption of VL and apneic oxygenation for managing difficult tracheal intubation was lower than expected, given recent recommendations by pediatric anesthesia societies. There was heterogeneity in how difficult intubation was defined, resulting in a possible patient safety risk.

Combined videolaryngoscopy and flexible bronchoscopy for difficult tracheal intubation in children: a retrospective observational cohort study

INTRODUCTION

Children with difficult airways are at high risk of complications. Alternative techniques to direct laryngoscopy for tracheal intubation include videolaryngoscopy, flexible bronchoscopy and the hybrid technique of simultaneous videolaryngoscopy and flexible bronchoscopy. This analysis aimed to compare the first-attempt success of each technique and assess the complications associated with difficult paediatric intubations in a quaternary paediatric institution.

METHODS

The electronic health records of a single quaternary paediatric hospital were searched to identify anaesthesia encounters involving difficult paediatric intubation. This was defined either by the Pediatric Difficult Intubation Registry criteria or as tracheal intubation requiring ≥ 3 attempts. Primary outcomes were the first-attempt success rate and incidence of complications with each tracheal intubation technique.

RESULTS

From April 2019 to January 2024, 559 encounters involving difficult tracheal intubation were identified. First-attempt success was highest for the hybrid technique (70/94, 74.5%) compared with videolaryngoscopy (143/235, 60.9%, p = 0.020) or direct laryngoscopy (19/190, 10.0%, p < 0.001). The hybrid technique was used to rescue 19/27 (70.4%) encounters where videolaryngoscopy alone was unsuccessful and was successful in all these encounters. Eighty-six (15.4%) encounters had at least one complication. The complication rate was significantly higher for patients weighing < 10 kg (45/184, 24.5%) compared with those weighing ≥ 10 kg (41/375, 10.9%, p < 0.001). The hybrid technique was associated with a lower incidence of complications (5/94, 5.3%) compared with videolaryngoscopy (33/235, 14.0%, p = 0.025) or direct laryngoscopy (41/190, 21.6%, p < 0.001).

DISCUSSION

In children with difficult tracheal intubation, the hybrid technique was associated with a higher first-attempt success rate compared with videolaryngoscopy alone or direct laryngoscopy. Consideration should be given to the hybrid technique as a first-line approach when difficult tracheal intubation is anticipated and when there is a failed attempt with either direct laryngoscopy or videolaryngoscopy.

Apnoeic oxygenation during paediatric tracheal intubation: a study protocol for a single-centre, cluster randomised clinical trial (ApOx-Pedi-Trial)

INTRODUCTION

Adverse events during paediatric anaesthesia are common, with hypoxaemia during the induction period being a leading cause, as infants and children are particularly vulnerable to hypoxaemia during periods of apnoea. The administration of supplementary oxygen, referred to as apnoeic oxygenation, has been shown to prolong safe apnoea times and increase first-pass intubation success rates. Despite these benefits, apnoeic oxygenation is not routinely used in paediatric anaesthesia. Low-flow apnoeic oxygenation, delivered via a standard nasal cannula, is a simple approach to provide supplementary oxygen during paediatric airway management without requiring additional equipment. However, its efficacy in airway management during elective surgeries has not been adequately studied.

METHODS AND ANALYSIS

The ApOx-Pedi-Trial is a single-centre, cluster randomised, controlled clinical trial comparing the use of low-flow apnoeic oxygenation during the induction of general anaesthesia in infants and children up to 6 years of age undergoing elective surgery at the Department of Pediatric Surgery at Heidelberg University Hospital to standard of care (no apnoeic oxygenation). Randomisation is conducted using a weekly cluster randomisation method, where all patients presenting for surgery in a given week either receive apnoeic oxygenation or standard of care during the induction of general anaesthesia, based on the week's group allocation.The study population will consist of two independent, age-stratified cohorts (<24 months and >24 months to 6 years), each including 100 patients. Statistical analysis of study endpoints will be conducted separately for each cohort to allow for age-specific assessment of outcomes.The primary objective of this trial is to evaluate whether apnoeic oxygenation can prevent a decrease in transcutaneous haemoglobin saturation (SpO₂) during the induction of general anaesthesia in infants and children. The primary outcome measure will be the lowest recorded SpO₂ value throughout the apnoeic period.

ETHICS AND DISSEMINATION

The ApOx-Pedi-Trial received permission from the local ethics committee (Ethics Committee of the medical faculty at Heidelberg University, Heidelberg, Germany) under the registration number S-074-2024. The study is following institutional Guidelines and the Declaration of Helsinki of 1975 in its most recent version. Trial results will be submitted to peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

The trial is prospectively registered on ClinicalTrials.gov with the number NCT06576596.

Structural, material and functional organisation of centres performing paediatric anaesthesia$,$$

OBJECTIVE

The French Society of Anesthesiology and Critical Care (Société Française d'Anesthésie et de Réanimation (SFAR)) and the French association of paediatric intensive care anaesthetists (Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF)) have joined forces to provide guidelines for professional practice on the structural, material, and functional organisation of centres performing pediatric anesthesia.

DESIGN

A consensus committee of 16 experts from the SFAR and the ADARPEF was convened. The experts declared no conflict of interest before and throughout the process. The entire guidelines process was conducted independently of any industry funding. The authors were asked to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Four fields were defined: 1) structure and logistics; 2) equipment and materials; 3) training; and 4) functional organisation. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out on works published from 2000 to 2022, using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. Because of the very small number of studies that could provide the necessary power for the most important endpoint (i.e., morbidity), it was decided, before drafting the recommendations, to adopt a Recommendations for Professional Practice (RPP) format rather than a Formalised Recommendations of Experts (RFE) format. The recommendations were formulated according to the GRADE® methodology, before being voted on by all the experts according to the GRADE grid method.

RESULTS

The experts' synthesis work and the application of the GRADE® method resulted in 34 recommendations dealing with the structural, material and functional organization of centers performing pediatric anaesthesia. After three rounds of rating and several amendments, an agreement was reached on all the recommendations.

CONCLUSIONS

Strong agreement exists among the experts to provide recommendations aimed at improving the structural, material and functional organization of centers performing paediatric anaesthesia.

Apnoeic oxygenation in pediatric anesthesia: better safe than sorry!

BACKGROUND

Children, especially neonates and infants, are at particularly high risk of hypoxemia during induction of anesthesia. The addition of nasal apnoeic oxygenation (ApOx) during tracheal intubation should prolong safe apnoea time without desaturation and reduce the risk of hypoxemia. Despite the recommendations in the relevant European guidelines, their implementation in pediatric anesthesia in Germany is not yet known.

METHODS

A survey was conducted in July and October 2024 via email to all registered members of the scientific working group on airway management, the scientific working group on pediatric anesthesia of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and hospitals of all levels in Germany. Participants were asked about their personal and institutional background and the use of ApOx in pediatric anesthesia in their institution.

RESULTS

Of the eight hundred participants invited, 304 anesthetists completed the survey (response rate 38%). In addition, 36 of 109 invited anesthetists from the scientific working group on pediatric anesthesia were interviewed as a separate expert group. 201 (66.1%) of the anesthetists surveyed in the general group stated that they worked regular in pediatric anesthesia (pediatric anesthesia expert group: 94.4%). 64.2% of the general respondents considered pediatric patients to be at an increased risk of reduced apnoea time. 46.7% of the general participants are of the opinion that pediatric patients should generally not receive ApOx during induction of anesthesia. If ApOx is performed, then most likely with a standard nasal cannula. ApOx was generally used in infants with an oxygen flow rate of ≤ 2 l/min or 0.2 l/kg bodyweight/min. A relevant proportion of anesthetists were unaware that current European guidelines recommend ApOx for neonates and infants (general participants: 62.5%, pediatric anesthesia expert group: 39%).

CONCLUSIONS

Despite the recommendations in the guidelines, the use of ApOx does not appear to be standard practice at present. Furthermore, the surveyed physicians exhibited considerable uncertainty regarding ApOx. It is imperative that further improvements are made in the dissemination of the current guidelines with a view to enhancing patient safety during pediatric anesthesia.

Videolaryngoscopy in paediatrics: in search of the clinical evidence

Despite the numerous recent trials, systematic reviews and meta-analyses have not conclusively shown superiority of videolaryngoscopy over other techniques for tracheal intubation of children. Clinical trials have shown significant differences using various outcome measures, but the overall clinical evidence remains weak. An international group of experts is currently working on developing good clinical research practice guidelines for paediatric airway management research, with the ultimate aim of identifying a core set of outcomes to be applied to develop future robust and comparable trials.

Clinical practice and outcomes in European pediatric cardiac anesthesia: A secondary analysis of the APRICOT and NECTARINE studies

BACKGROUND

Despite advancements in surgical techniques and perioperative care, pediatric cardiac patients remain at an increased risk of adverse events. The APRICOT (2017) study aimed to establish the incidence of severe critical events in children undergoing anesthesia in Europe, while the NECTARINE (2021) study aimed to assess anesthesia practices and outcomes in neonates and infants under 60 weeks postconceptual age. Our goal was to conduct a secondary analysis of the cardiac cohorts from these two studies to determine mortality rates and other outcomes after cardiac procedures at 30 and 90 days, identify factors influencing mortality, illustrate clinical practices, and assess the methodology of the two studies.

METHODS

Sub-analysis of the data from APRICOT and NECTARINE. Data representativity was assessed through a systematic categorization process. European countries were divided into four income groups based on their gross national income per capita. Subsequently, the total number of patients across all four income groups was calculated for both the Apricot and Nectarine studies, and then the specific contribution of each income group to the total population of each study was determined.

RESULTS

This analysis comprised 1016 cases (Apricot, n = 476 and Nectarine, n = 540). There was a considerable variability in clinical practice in Europe. The overall mortality rates were 0.84% (APRICOT) and 8.1% (NECTARINE). In both cohorts, substantial mortality was observed among low-age and low-weight infants. Stratifying the participating countries by income illustrated that the data originated from highest-income and upper-middle-income European countries and were not representative of low-income and middle-income countries.

CONCLUSIONS

In this secondary analysis of the APRICOT and NECTARINE studies, we found that fatal cases primarily occurred in low-age and low-weight neonates and infants.

EDITORIAL COMMENT

This secondary analysis of the APRICOT and NECTARINE studies focused on pediatric cardiac surgical cases. Outcomes differed according to weight and age of the children, where mortality risk was higher for very young and low-weight children.

Nasal Intermittent Positive Pressure Ventilation During Neonatal Endotracheal Intubation: A Randomized Controlled Trial

BACKGROUND

This prospective, multicenter, randomized controlled trial aimed to determine whether the use of nasal intermittent positive pressure ventilation (NIPPV) during neonatal endotracheal intubation increased the rate of successful intubation without physiological instability during all intubation attempts.

MATERIAL AND METHODS

In total, 150 infants were randomly assigned to either an NIPPV or standard care group (n = 75 each). The primary outcome was successful intubation without physiological instability (defined as ≥ 20% decline in the peripheral oxygen saturation [SpO2] from preintubation value or bradycardia with a heart rate < 100 beats/min) during all intubation attempts.

RESULTS

The mean postmenstrual age of the infants was 32.5 weeks, with a median weight of 1552 g at the time of intubation. The incidence of successful intubation without physiological instability during all intubation attempts was significantly higher in the NIPPV group (64%) than that in the standard care group (42.7%) (p = 0.009). This difference was particularly significant when inexperienced practitioners were involved. In the NIPPV group, the rates of bradycardia (18.7% vs. 41.3%) and severe desaturation (30.7% vs. 49.3%) were significantly lower, whereas the lowest SpO2 (85% vs. 76%) and lowest heart rate (118 vs. 105 beats/min) were significantly higher.

CONCLUSION

NIPPV during endotracheal intubation increased the incidence of successful intubation without physiological instability during intubation attempts in neonates while reducing the rate of hypoxia and bradycardia.

Heidelberg Adult and Pediatric Airway Registry (HAPA-Registry)

BACKGROUND

Advanced airway management is of fundamental importance in almost all areas of anesthesiology, emergency medicine, and critical care. Securing the airway is of the utmost importance, as this is a prerequisite for the oxygenation of the human organism. The clinical relevance of airway management is particularly evident in the fact that the primary cause of significant anesthesia-related complications can be attributed to this field. The need for the systematic recording of these procedures and their complications, as well as structured training in airway management and the evaluation of outcome parameters, is, therefore, evident.

METHODS

The HAPA-registry is a prospective and monocentric observational trial at the Department of Anesthesiology, Medical Faculty Heidelberg, University of Heidelberg, Germany. All patients requiring general anesthesia with consecutive advanced airway management during a surgical procedure were included. We, therefore, planned to include approximately 9000 patients in the first period. Following successful airway management, the anesthetist completed a case report form (CRF) in person. The intention was to record airway management cases on an annual basis for a period of several months, thus ensuring that the register remains up-to-date and that airway management procedures are continuously recorded.

DISCUSSION

The aim of this study was to establish an airway registry that enables the systematic recording and evaluation of different methods of airway management. The registry can be used to monitor and evaluate the implementation of current guidelines and recommendations for action, as well as the rates of success and complications.

Airway management may influence postoperative ventilation need in preterm infants after laser eye treatment

BACKGROUND

Retinopathy of prematurity is treated with laser photocoagulation under general anaesthesia with intubation using endotracheal tube (ETT), which carries a risk for postoperative mechanical ventilation (MV). Laryngeal mask airway (LMA) may provide a safe alternative. We assessed the need for postoperative MV in preterm infants who received LMA versus ETT.

METHODS

In this single-centre, retrospective cohort study, preterm infants who underwent laser photocoagulation between 2014-2021 were enroled. For airway management, patients received either LMA (n = 224) or ETT (n = 47). The outcome was the rate of postoperative MV.

RESULTS

Patients' age were 37 [35;39] weeks of postmenstrual age, median bodyweight of Group LMA was higher than Group ETT's (2110 [1800;2780] g versus 1350 [1230;1610] g, respectively, p < 0.0001). After laser photocoagulation, 8% of Group LMA and 74% of Group ETT left the operating theatre requiring MV. Multiple logistic regression revealed that the use of LMA and every 100 g increase in bodyweight significantly decreased the odds of mechanical ventilation (OR 0.21 [95% CI 0.07-0.60], and 0.73 [95% CI 0.63-0.84], respectively). Propensity score matching confirmed that LMA decreased the odds of postoperative MV (OR 0.30 [95% CI 0.11-0.70]).

CONCLUSION

The use of LMA is associated with a reduced need for postoperative MV.

IMPACT

Using laryngeal mask airway instead of endotracheal tube for airway management in preterm infants undergoing general anaesthesia for laser photocoagulation for treating retinopathy of prematurity could significantly decrease the postoperative need for mechanical ventilation. According to our current understanding, this has been the largest study investigating the effect of laryngeal mask airway during general anaesthesia in preterm infants. Our study suggests that the use of laryngeal mask airway is a viable alternative to intubation in the vulnerable population of preterm infants in need of laser treatment.

Common error traps in anesthesia for neonatal surgical emergencies

Neonatal surgical emergencies are challenging, often high-risk procedures for the pediatric anesthesiologist. Though each emergency presents different anesthetic challenges, several error traps exist that are common to all procedures in this patient population. These error traps include errors in surgical timing, airway management, maintenance of normothermia and normoglycemia, and recognition of pharmacologic and physiologic differences. In this narrative review, we will discuss each error trap to aid the clinician in recognizing, planning for, and mitigating adverse events.

Coaching inexperienced clinicians before a high stakes medical procedure: randomized clinical trial

OBJECTIVE

To assess whether training provided to an inexperienced clinician just before performing a high stakes procedure can improve procedural care quality, measuring the first attempt success rate of trainees performing infant orotracheal intubation.

DESIGN

Randomized clinical trial.

SETTING

Single center, quaternary children's hospital in Boston, MA, USA.

PARTICIPANTS

A non-crossover, prospective, parallel group, non-blinded, trial design was used. Volunteer trainees comprised pediatric anesthesia fellows, residents, and student registered nurse anesthetists from 10 regional training programs during their pediatric anesthesiology rotation. Trainees were block randomized by training roles. Inclusion criteria were trainees intubating infants aged ≤12 months with an American Society of Anesthesiology physical status classification of I-III. Exclusion criteria were trainees intubating infants with cyanotic congenital heart disease, known or suspected difficult or critical airways, pre-existing abnormal baseline oxygen saturation <96% on room air, endotracheal or tracheostomy tubes in situ, emergency cases, or covid-19 infection.

INTERVENTIONS

Trainee treatment group received preoperative just-in-time expert intubation coaching on a manikin within one hour of infant intubation; control group carried out standard practice (receiving unstructured intraoperative instruction by attending pediatric anesthesiologists).

MAIN OUTCOME MEASURES

Primary outcome was the first attempt success rate of intraoperative infant intubation. Modified intention-to-treat analysis used generalized estimating equations to account for multiple intubations per trainee participant. Secondary outcomes were complication rates, cognitive load of intubation, and competency metrics.

RESULTS

250 trainees were assessed for eligibility; 78 were excluded, 172 were randomized, and 153 were subsequently analyzed. Between 1 August 2020 and 30 April 2022, 153 trainees (83 control, 70 treatment) did 515 intubations (283 control, 232 treatment). In modified intention-to-treat analysis, first attempt success was 91.4% (212/232) in the trainee treatment group and 81.6% (231/283) in the control group (odds ratio 2.42 (95% confidence interval 1.45 to 4.04), P=0.001). Secondary outcomes favored the intervention, showing significance for decreased cognitive load and improved competency. Complications were lower for the intervention than for the control group but the difference was not significant.

CONCLUSIONS

Just-in-time training among inexperienced clinicians led to increased first attempt success of infant intubation. Integration of a just-in-time approach into airway management could improve patient safety, and these findings could help to improve high stakes procedures more broadly. Randomized evaluation in other settings is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04472195.

Error traps in patients with congenital heart disease undergoing noncardiac surgery

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.

Effect of positive end expiratory pressure on non-hypoxic apnea time and atelectasis during induction of anesthesia in infant: A randomized controlled trial

INTRODUCTION

This study aimed to assess the impact of positive-end-expiratory pressure (PEEP) on the non-hypoxic apnea time in infants during anesthesia induction with an inspired oxygen fraction of 0.8.

METHODS

This age stratified randomized controlled trial included patients under 1 year of age. Preoxygenation was performed using an inspired oxygen fraction of 0.8 for 2 min. Inspired oxygen fraction of 0.8 was administered via a face mask with volume-controlled ventilation at a tidal volume of 6 mL.kg-1, with or without 7 cmH2O of PEEP. Tracheal intubation was performed after 3 min of ventilation; however, it was disconnected from the breathing circuit. Ventilation was resumed once the pulse oximetry readings reached 95%. The primary outcome was the non-hypoxic apnea time, defined as the time from the cessation of ventilation to achieving a pulse oximeter reading of 95%. The secondary outcome measures included the degree of atelectasis assessed by ultrasonography and the presence of gastric air insufflation.

RESULTS

Eighty-four patients were included in the final analysis. In the positive end-expiratory pressure group, the atelectasis score decreased (17.0 vs. 31.5, p < .001; mean difference and 95% CI of 11.6, 7.5-15.6), while the non-hypoxic apnea time increased (80.1 s vs. 70.6 s, p = .005; mean difference and 95% CI of -9.4, -16.0 to -2.9), compared to the zero end-expiratory pressure group, among infants who are 6 months old or younger, not in those aged older than 6 months.

DISCUSSION

The application of positive end-expiratory pressure reduced the incidence of atelectasis and extended the non-hypoxic apnea time in infants who are 6 months old or younger. However, it did not affect the incidence of atelectasis nor the non-hypoxic apnea time in patients aged older than 6 months.

Prospective development and validation of a universal classification for paediatric videolaryngoscopic tracheal intubation: the PeDiAC score

BACKGROUND

The VIDIAC score, a prospectively developed universal classification for videolaryngoscopy, has shown excellent diagnostic performance in adults. However, there is no reliable classification system for videolaryngoscopic tracheal intubation in children. We aimed to develop and validate a multivariable logistic regression model and easy-to-use score to classify difficult videolaryngoscopic tracheal intubation in children and to compare it with the Cormack and Lehane classification. A secondary aim was to externally validate the VIDIAC score in children.

METHODS

We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ videolaryngoscopes in all children undergoing tracheal intubation for elective surgical procedures. We validated the VIDIAC score externally and assessed its performance. We then identified eligible co-variables for inclusion in the PeDiAC score, developed a multivariable logistic regression model and compared its performance against the Cormack and Lehane classification.

RESULTS

We studied 809 children undergoing 904 episodes of tracheal intubation. The VIDIAC score outperformed the Cormack and Lehane classification when classifying the difficulty of videolaryngoscopic tracheal intubation, with an area under the receiver operating characteristic curve of 0.80 (95%CI 0.73-0.87) vs. 0.69 (95%CI 0.62-0.76), respectively, p = 0.018. Eight eligible tracheal intubation-related factors, that were selected by 100-times repeated 10-fold cross-validated least absolute shrinkage selector operator regression, were used to develop the PeDiAC model. The PeDiAC model and score showed excellent diagnostic performance and model calibration. The PeDiAC score achieved significantly better diagnostic performance than the Cormack and Lehane classification, with an area under the receiver operating characteristic curve of 0.97 (95%CI 0.96-0.99) vs. 0.69 (95%CI 0.62-0.76), respectively, p < 0.001.

CONCLUSION

We developed and validated a specifically tailored classification for paediatric videolaryngoscopic tracheal intubation with excellent diagnostic performance and calibration that outperformed the Cormack and Lehane classification.

Universal paediatric videolaryngoscopy and glottic view grading: a prospective observational study

BACKGROUND

Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first-choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children.

METHODS

We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six-stage grading system.

RESULTS

There were 904 tracheal intubations in 809 children over a 16-month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway-related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59-0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73-0.87) for the direct glottic view during laryngoscopy (p = 0.005).

CONCLUSIONS

Universal, first-choice videolaryngoscopy reduced substantially the incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children.

Comparison of supraglottic airway device and endotracheal tube in former preterm infants receiving general anesthesia: a randomized controlled trial

To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT.

Assessment of risk factors for adverse events in analgosedation for pediatric endoscopy: A 10-year retrospective analysis

OBJECTIVES

Data regarding the occurrence of complications specifically during pediatric anesthesia for endoscopic procedures is limited. By evaluating such data, factors could be identified to assure proper staffing and preparation to minimize adverse events and improve patient safety during flexible endoscopy.

METHODS

This retrospective cohort study included children undergoing anesthesia for gastroscopy, colonoscopy, bronchoscopy, or combined endoscopic procedures over 10-year period. The primary study aim was to evaluate the incidence of complications and identify risk factors for adverse events.

RESULTS

Overall, 2064 endoscopic procedures including 1356 gastroscopies (65.7%), 93 colonoscopies (4.5%), 235 bronchoscopies (11.4%), and 380 combined procedures (18.4%) were performed. Of the 1613 patients, 151 (7.3%) patients exhibited an adverse event, with respiratory complications being the most common (65 [3.1%]). Combination of gastrointestinal endoscopies did not lead to an increased adverse event rate (gastroscopy: 5.5%, colonoscopy: 3.2%). Diagnostic endoscopy as compared to interventional had a lower rate. If bronchoscopy was performed, the rate was similar to that of bronchoscopy alone (19.5% vs. 20.4%). Age < 5.8 years or body weight less than 20 kg, bronchoscopy, American Society of Anesthesiologists status ≥ 2 or pre-existing anesthesia-relevant diseases, and urgency of the procedure were independent risk factors for adverse events. For each risk factor, the risk for events increased 2.1-fold [1.8-2.4].

CONCLUSIONS

This study identifies multiple factors that increase the rate of adverse events associated anesthesia-based endoscopy. Combined gastrointestinal procedures did not increase the risk for adverse events while combination of bronchoscopy to gastrointestinal endoscopy showed a similar risk as bronchoscopy alone.

Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features

Background/Objectives: Prediction of a difficult airway during pre-anesthetic evaluation is of great importance because it enables an adequate anesthetic approach and airway management. As there is a scarcity of prospective studies evaluating the role of anthropometric measures of the face and neck in predicting difficult airways in infants with an apparently normal airway, we aimed to identify the aforementioned predictors of difficult facemask ventilation and intubation in infants. Methods: A prospective, observational study that included 97 infants requiring general endotracheal anesthesia was conducted. Anthropometric and specific facial measurements were obtained before ventilation and intubation. Results: The incidence of difficult facemask ventilation was 15.5% and 38.1% for difficult intubation. SMD (sternomental distance), TMA (tragus-to-mouth angle distance), NL (neck length) and mouth opening were significantly lower in the difficult facemask ventilation group. HMDn (hyomental distance in neutral head position), HMDe (hyomental distance in neck extension), TMD (thyromental distance), SMD, mandibular development and mouth opening were significantly different in the intubation difficulty group compared to the non-difficult group. HMDn and HMDe showed significantly greater specificities for difficult intubation (83.8% and 76.7%, respectively), while higher sensitivities were observed in TMD, SMD and RHSMD (ratio of height to SMD) (89.2%, 75.7%, and 70.3%, respectively). Regarding difficult facemask ventilation, TMA showed greater sensitivity (86.7%) and SMD showed greater specificity (80%) compared to other anthropometric parameters. In a multivariate model, BMI (body mass index), COPUR (Colorado Pediatric Airway Score), BOV (best oropharyngeal view) and TMA were found to be independent predictors of difficult intubation, while BMI, ASA (The American Society Physical Status Classification System), CL (Cormack-Lehane Score), TMA and SMD predicted difficult facemask ventilation. Conclusions: Preoperative airway assessment is of great importance for ventilation and intubation. Patient's overall condition and facial measurements can be used as predictors of difficult intubation and ventilation.

[Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]

Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.

The Prevalence of Difficult Airway and Associated Risk Factors in Pediatric Patients: A Cross-sessional Observational Study

BACKGROUND

Difficult airway remains a great challenge in pediatric anesthesia practice. Previously published data show the prevalence of difficult airways in pediatric population varies in a wide range. However, there is a lack of studies in the Asian region.

METHODS

This cross-sectional single-center study was conducted in a tertiary pediatric hospital in China from October 2022 to October 2023. The patients who underwent elective surgery under general anesthesia with tracheal intubation were recruited consecutively. Data on patient characteristics, airway assessment, and airway management information were collected. Multivariable logistic regression analysis was performed to detect the independent variables of difficult airway in pediatric patients.

RESULTS

A total of 18,491 pediatric patients were included in this study. The overall incidence of difficult airways was 0.22%, 39% of whom were unanticipated. Very few previous airway management information was available in the patients presented with a known difficult airway. Patients with younger age, higher American Society of Anesthesiologists (ASA) physical status classification grade, and presented for craniofacial and thoracic surgery were associated with higher incidence of difficult airway. Further multivariable logistic regression analysis revealed that age ≤28 days (OR=50.48), age between 28days and 1 year (OR=6.053), craniofacial surgery (OR=1.81), and thoracic surgery (OR=0.2465) were independent risk factors of increased incidence of difficult airway.

CONCLUSIONS

Our study showed the prevalence of difficult airways in pediatric surgical patients. Patient characteristics, age, and type of surgery were identified as the independent factors associated with increased occurrence of difficult airways. Unanticipated difficult airway was not unusual in our study population, even for the patients with previous surgical history.

Lessons learned from big data (APRICOT, NECTARINE, PeDI)

Big data in paediatric anaesthesia allows the evaluation of morbidity and mortality of anaesthesia in a large population, but also the identification of rare critical events and of their causes. This is a major step to focus education and design clinical guidelines. Moreover, they can help trying to determine normative data in a population with a wide range of ages and body weights. The example of blood pressure under anaesthesia will be detailed. Big data studies should encourage every department of anaesthesia to collect its own data and to benchmark its performance by comparison with published data. The data collection processes are also an opportunity to build collaborative research networks and help researchers to complete multicentric studies. Up to recently, big data studies were only performed in well developed countries. Fortunately, big data collections have started in some low and middle income countries and truly international studies are ongoing.

Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists.

Delayed Sequence Intubation in Children, Why Not?

Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.

Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model

BACKGROUND

Rapid-sequence tracheotomy and scalpel-bougie tracheotomy are two published approaches for establishing emergency front-of-neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches.

AIMS

The aim of this cross-over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques.

METHODS

Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front-of-neck access using one and then the other technique: rapid-sequence tracheotomy and scalpel-bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation.

RESULTS

The median duration of the scalpel-bougie tracheotomy was 48 s (95% CI: 37-57), while the duration of the rapid-sequence tracheotomy was 59 s (95% CI: 49-66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: -4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%-98.2%). The scalpel-bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants.

CONCLUSIONS

The scalpel-bougie tracheotomy was slightly faster than the rapid-sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel-bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05499273.

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time

Background

The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications.

Methods

Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications.

Findings

First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications.

Interpretation

In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety.

Funding

None.

Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis

BACKGROUND

Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children.

METHODS

This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation.

RESULTS

After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration.

CONCLUSION

This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range.

CLINICAL TRIAL REGISTRATION

Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in a two-year-old child with a tongue tumor using video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation (hybrid technique)

Airway management in children can be challenging. A hybrid technique using a video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation allowed a successful airway management in a two-year-old child with a large tongue tumor.

From Brobdingnag to Lilliput: Gulliver's travels in airway management guidelines

Neonatal airway management comes with exclusive anatomical, physiological, and environmental complexities, and probably higher incidences of accidents and complications. No dedicated airway management guidelines were available until the recently published first joint guideline released by a task force supported by the European Society of Anaesthesiology and Intensive Care and the British Journal of Anaesthesia and focused on airway management in children under 1 yr of age. The guideline offers a series of recommendations based on meticulous methodology including multiple Delphi rounds to complement the sparse and scarce available evidence. Getting back from Brobdingnag, the land of giants with many guidelines available, this guideline represents a foundational cornerstone in the land of Lilliput.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Comparison of laryngeal mask airway and endotracheal tube in general anesthesia in children

At present, there is no relevant expert consensus indicating which ventilation device is more efficient for general anesthesia. The present literature review and meta-analysis compared the effects of the laryngeal mask airway and endotracheal intubation on airway complications during general anesthesia. The keywords 'laryngeal mask airway', 'endotracheal tube', 'tracheal tube', 'children', 'pediatric', 'anesthesia', 'randomized controlled trials' (RCTs) and 'randomized' were used to perform the literature search in PubMed. Quality assessment was performed by two reviewers according to domains defined by the Cochrane Collaboration tool. Data extraction, risk of bias assessment and quality of evidence assessment were performed with the Cochrane tool. A total of 16 RCTs were included. The results indicated that the effects of the laryngeal mask airway group on heart rate variability [mean difference=-13.76; 95% CI, -18.19-(-9.33); P<0.00001], the incidence of hypoxemia [odds ratio (OR)=0.52; 95% CI, 0.28-0.97; P=0.04] and the incidence of postoperative cough (OR=0.22; 95% CI, 0.12-0.40; P<0.0001) were significantly lower than those of the endotracheal intubation group. The success rate of one-time implantation in the laryngeal mask airway group was significantly higher than that noted in the endotracheal intubation group (OR=0.20; 95% CI, 0.07-0.59; P=0.003). However, no significant differences were noted between the two groups in bronchospasm, sore throat, mucosal injury, nausea and vomiting and reflux aspiration. In conclusion, the results indicated that laryngeal mask airway application can reduce complications during general anesthesia compared with endotracheal intubation.

The high-risk pediatric patient for ambulatory surgery

PURPOSE OF REVIEW

The aim of this article is to briefly review the pediatric ambulatory surgery landscape, identify two of the most common comorbidities affecting this population, examine the influence of pediatric obesity and sleep disordered breathing (SDB)/obstructive sleep apnea (OSA) on perioperative care, and provide information that can be used when formulating site specific criteria for ambulatory surgical centers.

RECENT FINDINGS

Most pediatric surgeries performed are now ambulatory, a majority of which take place outside of academic centers. Children with comorbidities such as obesity and SDB/OSA are undergoing surgical or diagnostic procedures which were previously deemed unacceptable for ambulatory surgery. The increase in pediatric ambulatory surgery coupled with a recent shortage of pediatric anesthesiologists means many children will receive anesthesia care from general clinicians who care for children intermittently and may be unfamiliar with the perioperative risks these comorbidities can present.

SUMMARY

Our pediatric ambulatory surgical population is anticipated to demonstrate increasing rates of obesity and SDB/OSA. Bringing attention to potential perioperative complications associated with these comorbidities provides a stronger foundation upon which to formulate criteria for individual ambulatory centers. It allows for targeted anesthetic management, influences provider assignments and/or staffing ratios, and informs scheduling times. For anesthesiologists who do not practice pediatric anesthesia daily, knowing what to anticipate plays a significant role in the ability to eliminate surprises and care for these patients safely.

Value of the Hyomental Distance Measured With Ultrasound in Forecasting Difficult Laryngoscopy in Newborns

PURPOSE

Preoperative evaluations of difficult airways are imperative, especially in newborns. The hyomental distance is a reliable index for predicting difficult airways in adults. However, few studies have evaluated the value of the hyomental distance for predicting difficult airways in newborns. It is unclear whether the hyomental distance forecasts a restricted or difficult view when using direct laryngoscopy. We intended to develop an effective system for predicting difficult tracheal intubation in newborns.

DESIGN

A prospective observational clinical study.

METHODS

Newborns aged 0 to 28 days undergoing oral endotracheal intubation with direct laryngoscopy for elective surgery under general anesthesia were enrolled. The hyomental distance and hyoid level tissue thickness were assessed by ultrasound. Other parameters, such as the mandibular length and sternomental distance, were also evaluated before anesthesia. The glottic structure view under laryngoscopy was graded according to the Cormack-Lehane classification. The patients with Grade 1 and 2 laryngeal views were assigned to Group E. Those with Grade 3 and 4 views were assigned to Group D.

FINDINGS

A total of 123 newborns were recruited for our study. The incidence of poor visualization of the larynx during laryngoscopy in our study was 10.6%. The multifactor logistic regression results showed that the hyomental distance was a powerful predictor of difficult laryngoscopy (OR = 0.16, 95% CI 0.03-0.74, P = .019). The curve with the highest sensitivity and specificity and the maximum area under the curve (AUC) was the hyomental distance. The receiver operating characteristic (ROC) curve for the hyomental distance suggested that the best cut-off value was less than equal to 2.74 cm, with an AUC of 0.80 (95% CI 0.64-0.95).

CONCLUSIONS

It is noninvasive and feasible to accurately measure the hyomental distance with ultrasound in newborns, and the results are reliable. We believe that the hyomental distance measured with ultrasound could be used as a marker for predicting difficult laryngoscopy in newborns.

Prevalence of Bradycardia After Induction of General Anesthesia and Associated Factors Among Surgical Pediatric Patients. A Prospective Observational Study

Background

Heart rate is the main determinant factor of the child's cardiac output in the first year of life. Thus, bradycardia decreases cardiac output leading to fatal cardiac arrhythmias, cardiac arrest, and even death. The objective of this study is to determine the prevalence of bradycardia and its associated factors after induction of general anesthesia among pediatric patients operated at Hawassa University Comprehensive Specialized Hospital (HUCSH).

Methods

Prospective observational study was employed at HUCSH by using a systematic random sampling technique. Pediatric surgical patients less than 6 years old were included in the study. Data were entered into Epi data statistical software (version 4.6.0.) and exported to SPSS (version 25.0). Categorical data were analyzed using chi-square statistics, and continuous data were analyzed using Student's t-test. Bivariable logistic regression was used to select candidate variables for multivariable logistic regression.

Results

The prevalence of bradycardia among 205 pediatric patients included in this study was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (halothane), difficult intubation, intraoperative complications, and significant surgical blood loss were independently associated with bradycardia.

Conclusion

The prevalence of bradycardia after induction of general anesthesia was 19.5%. Preoperative risk of hypoxia, opioids premedication, inhalational induction (particularly with halothane), difficult intubation, intraoperative complications such as hypoxia, and significant blood loss were significantly associated with bradycardia.

Neonatal airway management training using simulation-based educational methods and technology

Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.

The neonatal airway

Safe and effective management of the neonatal airway requires knowledge, teamwork, preparation and experience. At baseline, the neonatal airway can present significant challenges to experienced neonatologists and paediatric anaesthesiologists, and increased difficulty can be due to anatomical abnormalities, physiological instability or increased situational stress. Neonatal airway obstruction is under recognised, and should be considered an emergency until the diagnosis and physiological implications are understood. When multiple types of difficulties are present or there are multiple levels of anatomical obstruction, the challenge increases exponentially. In these situations, preparation, multi-disciplinary teamwork and a consistent hospital-wide approach will help to reduce errors and morbidity.

The difficult neonatal airway

Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.

An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists

BACKGROUND

Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS.

METHODS

For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. 'Time-to-vocal-cords', 'time-to-intubate', 'time-to-ventilate', the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded.

RESULTS

A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the 'time-to-intubate' or 'time-to-ventilate'. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating.

CONCLUSIONS

Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.

Outcome following anaesthesia in infancy in the Nordic countries: Subgroup analysis of the NECTARINE study

INTRODUCTION

The neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective observational study reported an incidence of 35.2% of critical events requiring intervention during 6542 anaesthetics in 5609 infants up to 60 weeks postmenstrual age (PMA) from 165 centres in 31 European countries.

METHODS

Sub-analysis of the cohort from the Nordic countries (8% of the entire cohort) was conducted. Secondary aims were to describe the Nordic countries' anaesthetic practices and compare morbidity and mortality with the overall European cohort.

RESULTS

Eleven Nordic centres recruited 447 infants (66% males, 37.3% born preterm and 45% had congenital anomalies) undergoing anaesthesia for 530 surgical or non-surgical procedures at 25-60 weeks PMA. Perioperative critical events triggered interventions in 228/530 (43%) cases. Hypotension (12.6%) or hypoxaemia (11.7%) were more common in younger patients and those with co-morbidities. Hypo/hypercapnia occurred in 1.5%/4.7% of cases. More than two attempts for intubation were required in 13 (2.9%) infants (max three attempts). Distribution of ASA-Physical Status Scores was similar to the total European cohort (40% was ASA > 2). A total of 236/530 (44.5%) patients were admitted to the postoperative intensive care unit. Thirty-day morbidity (complications in 87/447 = 19.5%) and mortality (8/447, 1.8%) did not differ from the overall European cohort. Hospital re-admissions were significant up to 90 days (98/447 = 21.9%).

CONCLUSIONS

In Nordic countries, anaesthesia in young infant children is resource-demanding, and perioperative critical events and co-morbidities are common. Thirty-day morbidity and mortality data in the Nordic countries did not differ from the overall European cohort.

Efficacy of McGRATH®MAC videolaryngoscope blade 1 for tracheal intubation in small children: a randomized controlled clinical study

BACKGROUND

Videolaryngoscopes may not be as effective in small children as they are in older children and in adults. The size 1 blade is commercially available for the McGRATH®MAC videolaryngoscope (Covidien, Medtronic, Tokyo, Japan), but its efficacy in comparison with a Macintosh laryngoscope blade 1 is not known.

AIM

The main aim of this study was to assess the efficacy of McGrath®MAC blade 1 in comparison with a conventional Macintosh laryngoscope blade 1, in children aged less than 24 months.

METHODS

Thirty-eight children aged less than 24 months were randomly allocated to one of two groups, and tracheal intubation was attempted using either a direct laryngoscope with a Macintosh blade 1 or a videolaryngoscope with a McGRATH®MAC blade 1. In another 12 children aged 2-4 years, the same comparisons were made with blade 2. The primary outcome measure was time to tracheal intubation using a size 1 blade.

RESULTS

Tracheal intubation took significantly longer with a McGRATH®MAC blade 1 (median (interquartile range): 38.0 (31.8-43.5) s) than with the Macintosh blade 1(27.4 (25.9-29.2) s) (p < 0.0001; median difference (95% CI for the median difference): 10.6 (6.4-14.0) s), mainly due to difficulty in advancing a tube into the trachea. No significant difference was observed for the size 2.

CONCLUSIONS

In small children without predicted difficult airways, time to intubate the trachea was significantly longer for a McGRATH®MAC blade 1 than a Macintosh blade 1.

CLINICAL TRIAL REGISTRATION

jRCT1032220366.

Preventing difficult facemask ventilation in children: all is well that starts well

Difficult facemask ventilation at induction of general anaesthesia can trigger hypoxaemia and inadequate ventilation if not immediately identified and adequately treated. For this reason, identification of predisposing conditions before induction of anaesthesia and causes of poor facemask ventilation are critical to avoid the subsequent complications. In a recently published secondary analysis of the Paediatric Difficult Intubation (PeDI) registry, the incidence and risk factors for difficult facemask ventilation in children with difficult tracheal intubation was described, as highlighted in the editorial.

Fiberoptic Intubation vs. Video-Assisted Fiberoptic Intubation in a High-Fidelity Pediatric Simulator: A Randomized Controlled Trial

INTRODUCTION

Life-threatening hypoxemia during tracheal intubation is more likely to occur in children than adults due to its unique physiological and anatomical nature. Fiberoptic intubation is widely performed in children with difficult airways. However, mastery of fiberoptic intubation requires substantial training, and novice trainees need to attempt fiberoptic intubation in children at high risk of respiratory-related adverse events. Therefore, a safer method than traditional fiberoptic intubation for children with difficult airways is desirable for novice anesthesia trainees. This study aimed to compare the efficacy of video-assisted fiberoptic intubation (VAFI) with that of traditional fiberoptic intubation (FOI) in a high-fidelity pediatric simulator by medical professionals with no experience in tracheal intubation.

METHOD

This randomized, controlled, simulation-based study was conducted in a tertiary-care pediatric hospital. Registered nurses working in the operating room were enrolled in this study and randomly assigned to either the FOI or VAFI groups. Participants in the FOI group performed fiberoptic intubation without the aid of any device, whereas those in the VAFI group used a video laryngoscope to obtain a better glottic view. The primary outcome was the time from the moment the tip of the flexible bronchoscope passed between the upper and lower incisors until the completion of tracheal intubation.

RESULTS

A total of 28 participants were enrolled in this study. There was no significant difference in the time until the completion of tracheal intubation between FOI and VAFI, with a median time of 55.0 seconds for FOI and 42.5 seconds for VAFI (P = 0.22). Secondary outcomes, including time until passing the vocal cord, the number of intubation attempts, and the first success rate, did not also illustrate the significant difference between the groups.

CONCLUSION

This study did not demonstrate the superiority of VAFI over conventional FOI in a high-fidelity pediatric simulator by medical providers with no experience in tracheal intubation.

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.