Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

Gálvez, Jorge A.; Acquah, Samuel; Ahumada, Luis M.; Cai, Lingyu; Polanski, Marcia; Wu, Lezhou; Simpao, Allan F.; Tan, Jonathan M.; Wasey, Jack O.; Fiadjoe, John E.

doi:10.1097/aln.0000000000002847

Cited by 44 publications

(35 citation statements)

References 17 publications

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“…Patients with airway bleeding did not have an increased requirement for the DART; however, bleeding was not quantified and was likely minimal in these patients. In contrast to literature identifying age less than one year as a risk factor for difficult intubation by anesthesia providers in the OR [2,11,12], our study showed that this age group did not need the DART more frequently than other age groups. This finding is more consistent with results from Graciano et al [3], who showed in univariate analysis that age < 2 years was associated with difficult intubation.…”

Section: Discussioncontrasting

confidence: 99%

Factors Associated With Pediatric Emergency Airway Management by the Difficult Airway Response Team

Dalesio

Burgunder

Díaz-Rodríguez

et al. 2021

Cureus

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BackgroundThe goal of this study was to determine if difficult airway risk factors were similar in children cared for by the difficult airway response team (DART) and those cared for by the rapid response team (RRT). MethodsIn this retrospective database analysis of prospectively collected data, we analyzed patient demographics, comorbidities, history of difficult intubation, and intubation event details, including time and place of the emergency and devices used to successfully secure the airway. ResultsWithin the 110-patient cohort, median age (IQR) was higher among DART patients than among RRT patients [8.5 years (0.9-14.6) versus 0.3 years (0.04-3.6); P < 0.001]. The odds of DART management were higher for children ages 1-2 years (aOR, 43.3; 95% CI: 2.73-684.3) and >5 years (aOR, 13.1; 95% CI: 1.85-93.4) than for those less than one-year-old. DART patients were more likely to have craniofacial abnormalities (aOR, 51.6; 95% CI: 2.50-1065.1), airway swelling (aOR, 240.1; 95% CI: 13.6-4237.2), or trauma (all DART managed). Among patients intubated by the DART, children with a history of difficult airway were more likely to have musculoskeletal (P = 0.04) and craniofacial abnormalities (P < 0.001), whereas children without a known history of difficult airway were more likely to have airway swelling (P = 0.04). ConclusionSpecific clinical risk factors predict the need for emergency airway management by the DART in the pediatric hospital setting. The coordinated use of a DART to respond to difficult airway emergencies may limit attempts at endotracheal tube placement and mitigate morbidity.

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Section: Discussioncontrasting

confidence: 99%

Factors Associated With Pediatric Emergency Airway Management by the Difficult Airway Response Team

Dalesio

Burgunder

Díaz-Rodríguez

et al. 2021

Cureus

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“…Tracheal intubation particularly in small children is a challenging procedure and successful tracheal tube insertion through the vocal cords should entail both a gentle laryngeal passage and a sufficient tracheal seal, once inflated . A too small tracheal tube cuff results in air leak with all the disadvantages of an unsealed tracheal airway; namely, an absent endtidal CO 2 signal in spite of correct tracheal intubation, imprecise endtidal‐CO 2 monitoring, impaired ventilation and oxygenation, environmental pollution with anesthetic gases with increased gas consumption and ultimately the risk of tube exchange, as is known from uncuffed tracheal tubes .…”

Section: Discussionmentioning

confidence: 99%

Cuffed pediatric endotracheal tubes—Outer cuff diameters compared to age‐related airway dimensions

Fischer

Grass

Kemper

et al. 2020

Pediatric Anesthesia

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Background: Reliable sealing of the pediatric airway requires appropriately sized tracheal tube cuffs. The aim of this study was to compare residual cuff diameters of pediatric tracheal tubes with pediatric airway dimensions. Methods: Cuff diameters of five different brands of locally marketed pediatric cuffed tracheal tubes with internal diameters of 3.0-7.0 mm were measured at a cuff pressure of 20 cm H 2 O and compared with cuff diameters indicated by their manufacturers. The latter values were compared to tracheal dimensions using the Motoyama and Khine formulas for cuffed tracheal tube size selection.Results: There is considerable heterogeneity in cuff diameters among pediatric tracheal tube brands, except for two brands from different manufacturers (Halyard and Parker Medical) which were identically designed. Cuffs made from polyurethane revealed fewer differences (91%-118%) between measured and manufacturer-indicated values for outer cuff diameters than did those made from polyvinylchloride (91%-146%).Particularly in smaller sized tracheal tubes, cuffs did not reach 100% of the tracheal lateral diameter, while others were oversized in larger tracheal tubes, independent of the two formulas used for cuffed tracheal tube size selection. Cuff diameters indicated by the manufacturer corresponded to 86%-188% of the median and 68%-157% of the maximum mid-tracheal lateral diameter of the corresponding upper age range. Conclusion:Our findings show that many of the cuff diameters of currently marketed tracheal tube brands lack an age-related anatomical rationale. A proposal for agerelated anatomically based cuff diameters is provided for both recommendations for cuffed tracheal tube size selection in children. K E Y W O R D S airway, airway equipment, pediatric | 425 FISCHER Et al. S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section. How to cite this article: Fischer M, Grass B, Kemper M, Weiss M, Dave MH. Cuffed pediatric endotracheal tubes-Outer cuff diameters compared to age-related airway dimensions. Pediatr

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“… Stinson et al 2018 166 1,448 Hospitalized pediatric patients Failure of intubation or SGA insertion on 1st attempt associated with progression of acute respiratory compromise to cardiac arrest (OR, 1.8; 95% CI, 1.2 to 2.6). Gálvez et al 2019 186 1,341 Infants: Operating room and diagnostic imaging 2 or more attempts associated with increased odds ratio of SpO 2 < 90% for at least one minute (OR, 1.78; 95% CI, 1.3 to 2.4). Amalric et al 2020 187 202 Critical care Complications occurred in 11% of those intubated on the first attempt; 32% with > 2 attempts ( P < 0.001).…”

Section: Response To An Unsuccessful First (Or Subsequent) Attempt At the Intended Airway Techniquementioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. Findings and key recommendations Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider “exit strategy” options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a “cannot ventilate, cannot oxygenate” emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as “airway lead” to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

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Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants

Cited by 44 publications

References 17 publications

Factors Associated With Pediatric Emergency Airway Management by the Difficult Airway Response Team

Factors Associated With Pediatric Emergency Airway Management by the Difficult Airway Response Team

Cuffed pediatric endotracheal tubes—Outer cuff diameters compared to age‐related airway dimensions

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

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