The clinical observation of difficult laryngoscopy and difficult intubation in infants with cleft lip and palate

Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series

BACKGROUND

Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population.

CASE PRESENTATION

A total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 μg/kg was administered within 10 minutes, and a maintenance dose of 1.5 μg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients.

CONCLUSION

Dexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

Retrospective Survey and Analysis of Anaesthesia and Outcomes in Paediatric Cleft Lip or Palate Surgery in a Tertiary Care Center, Portugal

INTRODUCTION

Orofacial clefts are the most common craniofacial abnormalities, affecting approximately one in 700 newborns each year. The anaesthetic management of these patients is challenging, including difficulties in airway approach and respiratory complications that have direct implications in the final outcome.

AIM

The present study aimed to characterize the anesthetic approach to paediatric patients undergoing cleft palate or lip surgical repair and review the perioperative anesthetic complications in a tertiary Portuguese hospital.

METHODS

Data were collected from a retrospective review of the patient records which included anaesthesia perioperative notes of paediatric patients submitted to cleft surgery repair during a five-year period (2016 to 2021). Demographic, pre-anaesthetic characteristics, anaesthetic management and perioperative complications were recorded.

RESULTS

A total of 102 patients were included, with a median age of 1.5 years. Congenital syndromes were present in 14 (13.7%) of the children included. Inhalational induction of anaesthesia with sevoflurane was the preferred approach in 86 cases (84.3%), with neuromuscular blockade being used in 59 cases (57.8%). Intubation was achieved at first attempt in 91 (89.2%) cases with four (3.9%) patients needing three or more attempts. Intraoperative respiratory-related complications were the most frequent, occurring in 22 (21.6%) cases. These include multiple attempts to intubation, desaturation due to bronchospasm or laryngospasm. The average length of stay was two days. Postoperative complications were recorded in 17 (16.7%) of patients.

DISCUSSION

The predominance of airway and respiratory complications occurring in cleft is consistent with previous studies. Care must be taken in order to avoid such complications in the perioperative period by following protocols, having skilled personnel, appropriate monitoring equipment and airway devices available during cleft surgeries to minimise morbidity.

The prevalence of difficult airway and its associated factors in pediatric patients who underwent surgery under general anesthesia: An observational study

Background:

The airway of an anesthetized patient should be secured with an artificial airway for oxygenation or ventilation. Pediatrics are not small adults which means they are different from adults both anatomically and physiologically. This study aims to determine the prevalence of difficult airway and its associated factors in pediatric patients who underwent surgery under general anesthesia in referral hospitals of Addis Ababa.

Methods:

A multi-centered cross-sectional study design was employed. The bivariable and multivariable logistic regression was used to measure the association between the dependent variable (pediatrics difficult airway) and independent variables. p-value < 0.05 was used to declare statistical significance.

Results:

A total of 290 pediatrics patients were included in this study. The prevalence of difficult airway in pediatrics patients who underwent surgery was 19.7%. In multivariate logistic regression, pediatrics patients less than 2 years of age (adjusted odds ratio = 6.768, 95% confidence interval = 2.024, 22.636), underweight pediatrics patients (adjusted odds ratio = 4.661, 95% confidence interval = 1.196, 18.154), pediatrics patients having anticipated difficult airway (adjusted odds ratio = 18.563, 95% confidence interval = 4.837, 71.248), history of the difficult airway (adjusted odds ratio = 8.351, 95% confidence interval = 2.033, 34.302), the experience of anesthetists less than 4 years of age (adjusted odds ratio = 9.652, 95% confidence interval = 2.910, 32.050) had a significant association with pediatrics difficult airway.

Conclusion:

Being pediatric patients less than 2 years of age, underweight pediatrics patients, having anticipated difficult airway, those anesthetists who do not perform enough pediatric cases were identified as the main factors associated with the greater occurrence of difficult airway in pediatric patients.

Videolaryngoscopic versus direct laryngoscopic paraglossal intubation for cleft lip/palate reconstructive surgeries: A randomised controlled trial

Background and Aims:

In the cleft lip and palate, the laryngoscope blade often tends to lodge inside midline clefts, causing reduced manoeuvrability and tissue trauma. The paraglossal technique avoids the midline and offers better Cormack Lehane (CL) grades. We aimed to assess the first-pass intubation rate in performing the left paraglossal laryngoscopy with a curved-blade videolaryngoscope (VLS) versus direct laryngoscope (DLS) in children with cleft palate and evaluate the time taken for successful endotracheal intubation (TTI) and Intubation Difficulty Score (IDS) with both devices.

Methods:

This randomised controlled trial included 60 patients with cleft palate, between 3 months and 6 years. Patients were randomised into group V (VLS) (n = 30) and group D (DLS) (n = 30). Left paraglossal laryngoscopy was done with VLS or DLS, and the first-pass intubation, TTI, CL grade and IDS were recorded.

Results:

First-pass intubation (primary outcome) was successful in all cases in group V and in 29 (96%) cases in group D (P = 0.923). Amongst the secondary outcomes, the IDS of the majority in both groups was 1–4 (slight difficulty) (P = 0.98) and the mean TTI In group D was 34.6 s (SD = 19.0) (95% CI: 27.5–41.7) versus 39.8 s (SD = 5.2) (95% CI: 37.8–41.7) in group V (P = 0.151).

Conclusions:

There was no significant difference in the use of a VLS over a DLS in performing the left paraglossal laryngoscopy in terms of first-pass intubation rate, CL Grade, IDS and TTI. Further studies with different VLS may be done to improve the ease of this technique.

Anesthetic Implications of Common Congenital Anomalies

The most common congenital anomalies are congenital heart defects, cleft lip and palate, Down syndrome, and neural tube defects. Anesthetic considerations for Down syndrome include cervical spine instability, history of congenital heart disease, risk of bradycardia, hematologic, endocrine, and behavioral considerations. Patients with cleft lip and palate can have associated syndromes, and the potential for underlying abnormalities should be investigated prior to their anesthetic. A major anesthetic consideration for neural tube defect surgery is positioning for intubation. Fetal surgery for myelomeningocele has been shown to reduce the need for ventriculoperitoneal shunting and improved motor outcomes.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Lip: An Analysis of 2126 Patients

ABSTRACT

Congenital cardiac comorbidities represent a potentially elevated risk for complications in patients undergoing cleft lip repair. National databases, such as the National Surgical Quality Improvement Program Pediatric (NSQIP-P) allow for analysis of large national datasets to assess these risks and potential complications. The aim of this study is to assess the risk of complications in patients undergoing cleft lip repair with congenital cardiac co-morbidities using the NSQIP-P.The 2012 to 2014 NSQIP-P databases were queried for patients undergoing cleft lip repair. Data abstracted for analysis included demographic, clinical, and outcomes data. Patients with cleft lip were stratified based on the presence or absence of congenital cardiac comorbidities. Univariate analysis and step-wise, forward logistic regression were performed to compare these groups.Nationally, between 2012 and 2014, 2126 patients underwent cleft lip repair, 227 with cardiac disease, and 1899 without cardiac disease. Weights were similar between the groups at the time of surgery, though patients with cardiac comorbidities were older. Postoperatively, cardiac disease patients were more likely to experience an adverse event. Specifically, they were more likely to experience reintubation, reoperation, longer length of stay, and death. Rates of surgical site infection and dehiscence were not different between the groups.This study demonstrates that cleft lip repair in patients with congenital heart defects is safe. However, patients undergoing cleft lip repair with comorbid congenital cardiac disease were more likely to experience adverse events. Cardiac patients require special preoperative evaluation before repair of their cleft lip, but do not appear to experience worse wound-related outcomes.

Incidence of Gastroesophageal Reflux Disease in Children With Cleft Lip and Palate and an Evaluation of Its Impact on Weight Gain

Patients with cleft lip and/or palate have higher rates of failure to thrive (FTT), decreased growth, and more often experience feeding difficulties as compared with the general pediatric population (J Child Health Care. 2014;18:72-83). Although insufficient nursing, excessive air intake, and incorrect feeding methods have been established in the literature, the role of gastroesophageal reflux disease (GERD) as a contributing factor in cleft patients has not been thoroughly examined. Presently, there is a paucity of literature analyzing the incidence and effect of GERD on this unique population. Furthermore, no studies have evaluated the effect of GERD therapy on improvement of weight gain and FTT in cleft patients. The purpose of this retrospective review was to identify the incidence of GERD in the orofacial cleft population and to see if appropriate treatment was effective in improving weight gain. Fifty patients with cleft lip, cleft lip and palate, and isolated cleft palate were identified from a single surgeon's experience at a large academic medical center from 2015 to 2019. The data show that a significantly higher percentage of patients with cleft lip/and or palate have clinical evidence of GERD, which required treatment as compared with published reports of less than 1% in the noncleft population. The data also suggest that the patients diagnosed with GERD who received pharmacologic treatment showed improved weight gain as compared with those who did not. Given our findings, the diagnosis of GERD should be considered in orofacial cleft patients exhibiting signs of feeding difficulty or those with FTT. The early diagnosis and treatment of GERD in patients with orofacial clefts may improve weight gain.

The Difficult Route to Glottis in Cleft Patients Simplified

Introduction

Cleft lip with or without palate is one of the most common craniofacial anomalies worldwide. Airway problems in children with cleft lip and palate were well recognized since very early times.

Objective

The aim of this technical note is to describe a unique method of performing direct laryngoscopy in children with cleft lip and palate by using a palatal obturator to cover the alveolar and palatal defect in these patients.

Methods

The palatal obturator was fabricated using cold cure acrylic after making an impression of the defect using putty-type impression material.

Results

The use of the palatal obturator facilitated the placement of the laryngoscope's blade by providing adequate leverage to it during the process of direct laryngoscopy prior to intubating children with cleft lip and palate defect.

Conclusion

A discontinuous alveolar arch and palatal defect contribute to lack of effective leverage of the laryngoscope blade while attempting visualization of the glottis. This difficulty can be overcome by use of an obturator to cover the alveolar and palatal defect in order to provide adequate leverage while using a laryngoscope for visualizing the glottis.

AMBU® LMA® in Children With Cleft Palate for Ophthalmic Surgery: A Case Report

Airway management remains a challenge in children, and the presence of a cleft palate further complicates the scenario. Endotracheal intubation, although definitive and most preferred, may be avoided for certain short-duration procedures wherein the use of laryngeal mask airway can allow quicker emergence. We present the successful airway management of 2 pediatric patients with cleft palate undergoing ophthalmological surgery, using AMBU® LMA® as the airway device of choice, which was further used as a rescue airway device in an emergent situation of "difficult to ventilate."

Usefulness of Airway Scope for intubation of infants with cleft lip and palate-comparison with Macintosh laryngoscope: a randomized controlled trial

Background

Airway Scope (AWS) with its plastic blade does not require a head-tilt or separate laryngoscopy to guide intubations. Therefore, we hypothesized that its use would reduce the intubation time (IT) and the frequency of airway complication events when compared with the use of Macintosh Laryngoscope (ML) for infants with cleft lip and palate (CLP).

Methods

The parents of all patients provided written consents; we enrolled 40 infants with CLP (ASA-PS 1). After inducing general anesthesia using sevoflurane and rocuronium, we performed orotracheal intubations using either AWS (n = 20) or ML (n = 20), randomly. We define the duration between manual manipulation using cross finger for maximum mouth opening and the first raising motion of the chest following intubation by artificial ventilation as “IT;” further, the measured IT as primary outcomes. Airway complications were considered secondary outcomes. Moreover, we looked for associations between IT and the patient’s characteristics: extensive clefts, age, height, and weight. We used the Mann–Whitney test and Fisher’s exact probability test for statistical analysis; p < 0.05 was considered as statistically significant.

Results

The mean IT was 31.5 ± 8.3 s in AWS group and 26.4 ± 8.9 s in ML group. Statistical significant difference was not found in IT between the two groups. The IT of AWS group was statistically related to extensive clefts. Airway complications were detected in ML group.

Conclusion

AWS could be useful for intubation of infants with CLP; it required IT similar to that required using ML, with a lower rate of airway complications.

Trial registration

UMIN-CTR Registration number UMIN000024763.

Registered 8 November 2016.

Predicting Adverse Perioperative Events in Patients Undergoing Primary Cleft Palate Repair

Objective:

This study aimed to identify risk factors for adverse perioperative events (APEs) after cleft palatoplasty to develop an individualized risk assessment tool.

Design:

Retrospective cohort.

Setting:

Tertiary institutional.

Patients:

Patients younger than 2 years with cleft palate. Interventions: Primary Furlow palatoplasty between 2008 and 2011.

Main Outcome Measure(s):

Adverse perioperative event, defined as laryngo- or bronchospasm, accidental extubation, reintubation, obstruction, hypoxia, or unplanned intensive care unit admission.

Results:

Three hundred patients averaging 12.3 months old were included. Cleft distribution included submucous, 1%; Veau 1, 17.3%; Veau 2, 38.3%; Veau 3, 30.3%; and Veau 4, 13.0%. Pierre Robin (n = 43) was the most prevalent syndrome/anomaly. Eighty-three percent of patients received reversal of neuromuscular blockade, and total morphine equivalent narcotic dose averaged 0.19 mg/kg. Sixty-nine patients (23.0%) had an APE, most commonly hypoventilation (10%) and airway obstruction (8%). Other APEs included reintubation (4.7%) and laryngobronchospasm (3.3%). APE was associated with multiple intubation attempts (odds ratio [OR] = 6.6, P = .001), structural or functional airway anomaly (OR = 4.5, P < .001), operation >160 minutes (OR = 2.2, P = .04), narcotic dose >0.3 mg/kg (OR = 2.3, P = .03), inexperienced provider (OR = 2.1, P = .02), and no paralytic reversal administration (OR = 2.0, P = .049); weight between 9 and 13 kg was protective (OR = 0.5, P = .04). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (APE 2.5%-91.7%) with excellent risk discrimination (C-statistic = 0.79).

Conclusions:

APE incidence was 23.0% after palatoplasty, with a 37-fold higher incidence in extreme-risk patients. Individualized risk assessment tools may enhance perioperative clinical decision making to mitigate complications.

An observational study of the feasibility of Airtraq guided intubations with Ring Adair Elvin tubes in pediatric population with cleft lip and palate

Context:

The airway management requires refined skills and technical help when associated with cleft lip and palate. Airtraq has improved our airway management skills and has been successfully used for rescue intubation in difficult pediatric airways.

Aims:

This study was to evaluate the efficacy of Airtraq as the primary intubation device in patients with cleft lip and palate. The study adheres to the STrengthening the Reporting of OBservational Studies Epidemiology Statement.

Subjects and Methods:

A total of 85 children posted consecutively for lip and palate repair were enrolled. Children were intubated with Ring Adair Elvin (RAE) tube using size 1 and 2 of Airtraq device. The design of Airtraq has an anatomical limitation to hold RAE tubes. The preformed bend of the tube was straightened with a malleable stylet. The intubations were assessed for device manipulations and time taken for glottis visualization and intubation, airway complications such as bleeding, laryngospasm and failed intubations.

Statistical Analysis Used:

The outcome data were reported as numbers and percentages or range with identified median value, where applicable.

Results:

The success rate of Airtraq guided intubations was 98.21%. The cumulative insertion times and intubation times were 31.50 ± 12.57 s and 48.04 ± 35.73 s respectively. Airtraq manipulations were applied in 25.45% subjects.

Conclusions:

The presence of cleft lip or palate did not hamper the insertion of Airtraq. The use of malleable stylet to facilitate the loading of the preformed tube into the guide channel is a simple and efficacious improvisation. Airtraq can be utilized as a primary intubation device in children with orofacial clefts.

An Assessment of 30-Day Complications in Primary Cleft Lip Repair: A Review of the 2012 ACS NSQIP Pediatric

OBJECTIVE

The aim of this study is to identify risk factors associated with complications and readmissions following cleft lip repair using the multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric.

DESIGN

Patients undergoing CPT codes 40700, 40701, and 40702 were extracted from the ACS NSQIP Pediatric. Fisher exact, χ(2), and rank-sum tests were used to evaluate risk factors.

RESULTS

Of the 525 patients included, 4.2% had complications, with respiratory complications being the most common. Risk factors included congenital malformations (P = .001), ventilator dependence (P = .002), oxygen support (P = .016), tracheostomy (P = .005), esophageal/gastric/intestinal disease (P = .007), impaired cognitive status (P = .034), acquired central nervous system abnormality (P = .040), nutritional support (P = .001), major and severe cardiac risk factors (P = .011 and P = .005), and an American Society of Anesthesiologists score of 3 (P = .002). In addition, complications were associated with undergoing a one-stage bilateral repair (P = .045) or concomitant ear, nose, and throat procedure (P = .045). The readmission rates for ambulatory patients and inpatients were 2.6% and 4.9% (P = .556), with an overall readmission rate of 4.6%. Ambulatory patients were older (P = .005) and had shorter operative times (P < .001).

CONCLUSIONS

Perioperative complications are low following cleft lip repair, with respiratory complications being the most common. Readmission rates of 4.6% are higher than expected, and insight into predictors of complications will allow surgeons to identify patients who could benefit from additional resources.

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.

Simple solution for difficult face mask ventilation in children with orofacial clefts

Significant air leak from the facial cleft predisposes to difficult mask ventilation. The reported techniques of use of sterile gauze, larger face mask and laryngeal mask airway after intravenous induction have limited application in uncooperative children. We describe the use of dental impression material molded to the facial contour to cover the facial defect and aid ventilation with an appropriate size face mask in a child with a bilateral Tessier 3 anomaly.

Management of Difficult Airway in a Failed Intubation with Videolaryngoscopy in an Infant Patient

The videolaryngoscope is a useful alternative airway device for anaesthesia management of difficult airways. However videolaryngoscope intubation may fail due to lack of experience, incorrect application, inappropriate stylet, prior traumatic attempts, restricted cervical movement and limited oropharyngeal airspace. Using a stylet and correctly shaped endotracheal tube is important to facilitate tracheal intubation with the videolaryngoscope, especially in paediatric patients. However, anatomical difficulty in the placement of the laryngoscope blade, association with facial deformities such as micrognathia, having a short neck, cleft palate and being younger than 1 year increase the likelihood of a difficult airway. In this report, we present our approach to difficult airway management in a failed intubation with a videolaryngoscope in an infant undergoing cleft palate surgery.

Management of difficult airway patients and the use of a difficult airway registry at a tertiary care pediatric hospital

BACKGROUND

Appropriate recognition and management of the pediatric difficult airway is essential. Two patient deaths in a 2-year period involving children with a known difficult airway led to the formation of the institution's multidisciplinary Difficult Airway Committee.

METHODS

Patients with a suspected difficult airway or a known difficult airway are entered into a registry of difficult airway patients. A note describing the airway and any experiences at airway manipulation is entered as part of a difficult airway note in the patient's electronic medical record as soon as the patient is recognized as having a difficult airway. A call system has been developed to mobilize expert emergency airway assistance for these patients. Multiple additional methods are employed to ensure that all hospital personnel are aware that these patients are difficult to intubate.

RESULTS

Since inception almost 6 years ago, 164 patients (mean age 9.2 years) have been enrolled in the difficult airway registry. Eighty-seven patients (53%) had one of 28 identified syndromes or diagnoses. The most common reasons for airway obstruction were mandibular hypoplasia/micrognathia, decreased neck extension, and limited temporomandibular joint mobility. One hundred sixty-one patients (98%) in the registry were predicted by history or physical to have a difficult airway. The mortality of registry patients was 9.8% (n = 16) and was most commonly due to co-existing diseases. During the time period reviewed, there was one in-hospital death of a known difficult airway patient, in which expert airway assistance was not obtained in a timely fashion.

CONCLUSION

The institution's difficult airway registry identifies patients with a suspected or known difficult airway. The presence of a difficult airway in children can usually be predicted based on history and physical examination by anesthesiologists and otolaryngologists. Providers without advanced airway skills, however, may not appreciate that an airway is difficult to intubate until multiple attempts have failed. Both redundant notification methods and a call system optimize medical care of these fragile patients.

Features of lateral cephalograms associated with difficult laryngoscopy in Japanese children undergoing oral and maxillofacial surgery

BACKGROUND

Difficult laryngoscopy and tracheal intubation are occasionally encountered in children with congenital anomalies or micrognathia. However, no study has elucidated anatomical etiology in relation to craniofacial development.

METHODS

Two hundred ten patients aged 8 months-18 years were analyzed. We analyzed the lateral cephalograms of: (i) eight patients in whom laryngoscopy was anticipated as difficult before anesthesia and who were unable to be intubated by direct laryngoscopy and needed fiberoptic bronchoscopy (group A); (ii) 11 patients in whom laryngoscopy was anticipated as difficult before anesthesia but who were able to be intubated by direct laryngoscopy (group B); and (iii) 191 patients in whom laryngoscopy was anticipated as easy before anesthesia and was actually found to be easy (group C). Eight cephalometric parameters were measured and age-parameter relationships were plotted. Logistic regression analysis was performed to characterize group A children for each of the cephalometric variables.

RESULTS

Apparently insufficient growth of the mandible was observed in the group A children. Furthermore, the group A children of aged <4 years had undeveloped maxilla, longer mandibular plane-hyoid distances (≥1.3 cm), and deeper depth of the oropharynx; those of aged ≥4 years showed increased inclination of the mandible (sella-nasion plane to mandibular plane angle of ≥46.5°).

CONCLUSIONS

Difficult laryngoscopy and tracheal intubation are expected in children aged <4 years with lower-positioned hyoid bone caused by caudal larynx as well as undeveloped maxilla and mandible, and in those aged ≥4 years with increased inclination of the mandible as well as undeveloped mandible.

Perioperative Risk Factors for Adverse Airway Events in Patients Undergoing Cleft Palate Repair

Objective

To establish the incidence of perioperative airway complications in a large series of pediatric patients undergoing palatoplasty and to identify which specific patient, procedural, and provider factors are associated with increased risk for perioperative adverse airway events (AAEs).

Design

Retrospective chart review.

Setting

Tertiary pediatric hospital.

Patients

Included were 300 patients who underwent primary cleft palate repair using the modified Furlow technique between 2008 and 2011. Patients were 2 years or younger at the time of the operation.

Main Outcome Measure(s)

Charts were reviewed for perioperative AAEs, which were defined as postoperative airway obstruction, oxyhemoglobin saturation ≤85% for ≥45 seconds, bronchospasm, laryngospasm, reintubation, and unplanned admission to the intensive care unit. Patient-specific factors (diagnosis of a craniofacial syndrome, Veau cleft type, preoperative pulmonary and airway history), procedural factors (operative time, anesthesia time, opioid dose, administration and reversal of neuromuscular blockers), and provider factors (experience, number of providers), were documented, and associations with AAEs were investigated.

Results

AAEs occurred in 23% of patients overall and were significantly more common in syndromic patients ( P = .003), patients with jaw or tracheal anomalies ( P = .001), and patients with a history of difficult airway ( P = .001). Other significant factors included prior history of difficult intubation ( P = .05), surgeon ( P = .02) and anesthesiologist experience ( P = .05), and operative time ( P = .02).

Conclusions

Diagnosis of a craniofacial syndrome, a history of preoperative airway problems, and provider inexperience correlated with increased risk for airway complications after palatoplasty. Recognizing patients at risk for AAEs may permit improved preoperative planning to optimize surgical outcomes and minimize complications.

Proper size of endotracheal tube for cleft lip and palate patients and intubation outcomes

OBJECTIVES

The aim of the current study was to identify the proper size of endotracheal tube for intubation of cleft lip and palate patients and intubation outcomes in these patients.

PATIENTS AND METHODS

In this analytic cross-sectional study, 60 nonsyndromic cleft lip and palate patients were selected who had surgery between April 2010 and April 2012 at Pediatrics Hospital, Tabriz University of Medical Sciences, Iran. Demographic findings, previous admissions, and surgical history were registered. The proper tube size was measured by normal children formulas. Then tube size was confirmed by patients' minimum resistance to intubation, proper ventilation reported by anesthesiologist, and appropriate air leakage at an airway pressure of 15-20 cm H₂O. If intubation was unsuccessful then smaller size of endotracheal tube would be tried. Frequency of intubation trials and the biggest endotracheal tube size were recorded.

RESULTS

Their average age, weight and height were 21.39 ± 4.95 months, 9.97 ± 1.18 kg and 74.30 ± 26.61 cm, respectively. The average tracheal tube size and frequency of intubation trials were 4.34 ± 0.78 and 1.63 ± 0.80, respectively. Seven cases required an endotracheal tube size smaller than the recommended size for that age including one case in unilateral cleft palate, three cases in unilateral cleft lip, one case in unilateral cleft lip and palate, and two cases in bilateral cleft lip and palate.

CONCLUSIONS

Findings proved that considering subglottic stenosis incidence in these children, it is reasonable to determine the tube size for nonsyndromic cleft lip and palate patients by applying the currently available standards for normal children.

A novel intubation technique in bilateral cleft palate pediatric patients: hard gum shield-aided intubation

BACKGROUND

Cleft palate anesthesia is challenging due to difficult airway. Left paraglossal intubation moves resting point of laryngoscope laterally but associated with narrower laryngoscopic view and possible trauma, and we invented the use of hard gum shield as a bridge over defective palate to facilitate intubation with possible wider window and defective tissue protection.

METHODS

Eighty bilateral cleft palate children, ASA physical status I-II aged 9 months to 6 years scheduled for plastic surgery had general anesthesia, were involved in prospective, controlled, randomized study, and were randomly divided by closed envelope method into two groups: group I (40 patients): intubated by hard gum shield-aided intubation and group II (40 patients): intubated by left paraglossal intubation. Both techniques compared as regards (i) intubation time; (ii) Cormack and Lehane score; (iii) need for external laryngeal manipulation; (iv) easiness of intubation: easy, modest, or difficult intubation; and (v) complications: desaturation and failed intubation.

RESULTS

Intubation time was shorter in group I (28.47 ± 3.78 vs. 37.63 ± 6.64 s, P = 0.001). Cormack and Lehane score was better in group I (P = 0.003). Need for external laryngeal manipulation was less in group I (P = 0.015). Easiness of intubation was better in group I (P = 0.022). No difference was found in complications between groups.

CONCLUSION

Hard gum shield-aided intubation facilitated intubation more than left paraglossal in bilateral cleft palate children with shorter intubation time, better glottic view, easier intubation, less need for laryngeal manipulation than left paraglossal intubation with no difference in complications.

Airway and respiratory complications in children undergoing cleft lip and palate repair

OBJECTIVES

Anatomical abnormalities associated with cleft lip and palate increase the risk of airway complications. The aim of this study was to determine the incidence of intra-operative airway and respiratory complications during cleft lip and palate repair and identify risk factors.

DESIGN

Observational study in which fifty consecutive patients undergoing cleft lip or/ and palate repair (CL, CP, CLP) were prospectively studied in a teaching hospital in Nigeria. Anaesthesia was achieved by the inhalational or intravenous route. Tracheal intubation was performed under deep inhalational anaesthesia or muscle relaxation. All patients were ventilated. Demographic data, airway and respiratory complications were documented.

RESULTS

The mean age of the patients was 26.62± 4.71(SEM) months (median 11.50). Nineteen airway complications occurred in 16 patients (incidence - 38%) as failed and difficult intubation (2% respectively) which only occurred in CP surgeries, Tube disconnection (6%), Tube compression (2%), Accidental extubation (2%) and Desaturation (14%). Laryngeal spasm (6%) and Bronchospasm (4%) occurred in surgeries for CP repair only. Some patients had more than one complication. Complications occurred in 38.4% of patients having CP repair, 15.8% having CL repair and 50% having CLP repair (p=0.185). This was not influenced by weight nor age group (p = 0.076 and 0.400 respectively).

CONCLUSION

Cleft repair had a high incidence of airway/ respiratory complications. More complications occurred with CP surgery. There is a need to ensure adequately skilled personnel and appropriate monitoring to minimise morbidity.

Anesthetic experience of 100 pediatric tracheostomies

BACKGROUND

Tracheostomy is more hazardous in the pediatric population than in adults (Paediatr Nurs, 17, 2005, 38; Int J Pediatr Otorhinolaryngol, 67, 2003, 7; J R Soc Med, 89, 1996, 188). Airway management in these children and infants is potentially challenging. Previous case series of pediatric tracheostomy published in the surgical journals make little mention of anesthetic techniques used and do not describe airway management. The aim of this study was to review the anesthetic, and in particular the airway management of children undergoing tracheostomy at Great Ormond Street Hospital (GOSH).

METHODS

Between September 2004 and December 2007, the ENT surgical database showed that 109 children had a surgical tracheostomy performed at GOSH. We were only able to locate the notes of 100 of these cases. The anesthetic records of these 100 patients undergoing tracheostomy were analyzed retrospectively.

RESULTS

Ninety-four percent (94/100) of tracheostomies were elective, and 6% (6/100) were emergency. In this study, 26% (26/100) of children were recorded as difficult to intubate. These difficult airways were managed as follows: 10/26 used a laryngeal mask airway (LMA), 5/26 were managed with facemask alone, 3/26 had fiber-optic intubation, 5/26 had surgical intubation and 2/26 were intubated with the aid of a bougie and cricoid pressure.

CONCLUSIONS

This case series demonstrates that intubation is difficult in up to 26% of children presenting for tracheostomy. While intubation of the trachea remains the preferred option when anesthetizing children for tracheostomy, the LMA or facemask can provide a successful airway where intubation is not possible. The use of the LMA or facemask may therefore be life saving in the unintubatable child.

A left paraglossal approach for oral intubation in children scheduled for bilateral orofacial cleft reconstruction surgery--a prospective observational study

BACKGROUND

Children with orofacial cleft defects are expected to have difficult airways. Conventional midline laryngoscopic approach of oral intubation can lead to iatrogenic tissue trauma. In this study, we evaluated the feasibility of left paraglossal laryngoscopy as a primary technique for airway management in these children.

METHODS

After institutional ethical committee approval and informed consent, we enrolled 21 children with uncorrected bilateral lip and palate deformities (BL CL/P). Anesthesia was induced with halothane (0.5-4%) in 100% oxygen. After obtaining intravenous access, fentanyl 1.5 microg x kg(-1) and atracurium 0.5 mg x kg(-1) were administered. Endotracheal intubation was performed with Miller's straight blade laryngoscope, introduced using left paraglossal approach. Difficulty of intubation was scored according to modified Intubation Difficulty Scale.

RESULTS

Data consists of 21 children (15 males and six females), mean age 1.31 +/- 1.18 years and weight 9.27 +/- 2.57 kg. Laryngoscopic view obtained was CL II (7[33.3%]) and CL I (14[66.6%]) respectively (Figure 1). All the children could be easily intubated using left paraglossal approach, only 2/3 of them needed optimal external laryngeal manipulation to help achieving it. Though intubation could be done in the first attempt in 19 children, two infants (9 1/2 and 11 months) required one size smaller endotracheal tube and were intubated in the second attempt using left paraglossal approach. Perioperative course was uneventful in all the children.

CONCLUSION

Keeping in mind midline tissue support loss in cleft deformities, we propose routine use of left paraglossal laryngoscopic approach for intubating children with uncorrected BL CL/P anomalies.

Blood pressure and heart rate changes during fibreoptic orotracheal intubation: a comparison of children and adults

BACKGROUND AND OBJECTIVES

Autonomic circulatory regulation and airway anatomy in children are significantly different from those in adults. There is no available published data to compare whether there is a clinically relevant difference in the haemodynamic responses to fibreoptic orotracheal intubation (FOI) under the same conditions between children and adults. In this randomized clinical study, we compared the blood pressure (BP) and heart rate (HR) changes during FOI in 40 children aged 3.5-9 yr and 40 adults aged 21-57 yr, ASA 1 scheduled for elective plastic surgery under general anaesthesia requiring orotracheal intubation.

METHODS

Anaesthesia was induced with intravenous (i.v.) injection of fentanyl and propofol, and face mask inhalation of isoflurane before FOI. Noninvasive BP and HR were recorded before induction (baseline values), after induction (postinduction values), at intubation and for 5 min after intubation at 1-min intervals. The percentage changes of BP and HR at each time point were calculated.

RESULTS

In children and adults, HR at intubation and 1-3 min after intubation were significantly higher than baseline and postinduction values. In adults, BP at intubation increased significantly compared to the postinduction values but did not exceed baseline values. In children, BP at intubation and 1 min after intubation were significantly higher than postinduction and baseline values. As compared to adults, FOI caused a more significant pressor response in children. The percentage changes of BP at intubation and 1 min after intubation were larger in children than in adults. However, there was no significant difference in the percentage change of HR during the observation between children and adults.

CONCLUSIONS

Under general anaesthesia, FOI might cause a more significant pressor response in children than in adults.