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 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)

An Unusual Lacerated Tracheal Tube during Le Fort Surgery: Literature Review and Case Report

Maxillofacial surgeries can present unique anesthetic challenges due to potentially complex anatomy and the close proximity of the patient’s airway to the surgical field. Damage to the tracheal tube (TT) during maxillofacial surgery may lead to significant airway compromise. We report the management of a patient with a partially severed TT during Le Fort surgery for midfacial hypoplasia and management strategies based on peer-reviewed literature. This case illustrates the clinical clues associated with a damaged TT and explores the challenges of managing this potentially catastrophic issue

Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry

Background: Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of this study was to compare the first-attempt success rate of tracheal intubation during sedated tracheal intubation versus tracheal intubation under general anesthesia. The hypothesis was that sedated intubation would be associated with a lower first-attempt success rate and more complications than general anesthesia. Methods: This study used data from an international observational registry, the Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. The use of sedation versus general anesthesia for tracheal intubation were compared. The primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and nonsevere and severe complications. Propensity score matching was used with a matching ratio up to 1:15 to reduce bias due to measured confounders. Results: Between 2017 and 2020, 34 hospitals submitted 1,839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation, and 1,764 patients received general anesthesia. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the general anesthesia group. The rate of first-attempt success of tracheal intubation was 28 of 58 (48.3%) in the sedation group and 250 of 522 (47.9%) in the general anesthesia group (odds ratio, 1.06; 95% CI, 0.60 to 1.87; P = 0.846). The median number of intubations attempts was 2 (interquartile range, 1 to 3) in the sedation group and 2 (interquartile range, 1, 2) in the general anesthesia group. The general anesthesia group had 6 of 522 (1.1%) intubation failures versus 0 of 58 in the sedation group. However, 16 of 58 (27.6%) sedation cases had to be converted to general anesthesia for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low. Conclusions: Sedation and general anesthesia had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to general anesthesia to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low

The effects of a hands-free communication device system in a surgical suite

This case report describes a qualitative investigation into how a Hands-free Communication Device (HCD) system impacted communication among anesthesia staff in a pediatric surgical suite. The authors recruited a purposive sample that included anesthesiologists, certified registered nurse anesthetists, circulating nurses, a charge nurse, and a postanesthesia care unit nurse. Data were collected using semistructured interviews and observations, then analyzed using a constant comparison approach. The results corroborate and enrich themes that were discovered in a previous qualitative study of HCD systems: (1) communication access, (2) control, (3) training, (4) environment and infrastructure. The results also generated new subthemes and themes: (1) technical control, (2) choosing communication channels, and (3) reliability. The authors conclude that HCD systems profoundly impacted communication in a largely positive way, although reliability of the technology remained an issue. The authors' findings contribute a valuable insight into the growing body of knowledge about implementation and use of HCD systems

A framework for the management of the pediatric airway

Critical airway incidents in children are a frequent problem in pediatric anesthesia and remain a significant cause of morbidity and mortality. Young children are at particular risk in the perioperative period. Delayed management of airway obstruction can quickly lead to serious complications due to the short apnea tolerance in children. A simple, time critical, and pediatric-specific airway management approach combined with dedicated teaching, training, and frequent practice will help to reduce airway-related pediatric morbidity and mortality. There is currently no pediatric-specific universal framework available to guide practice. Current algorithms are modifications of adult approaches which are often inappropriate because of differences in age-related anatomy, physiology, and neurodevelopment. A universal and pragmatic approach is required to achieve acceptance across diverse pediatric clinicians, societies, and groups. Such a framework will also help to establish minimum standards for pediatric airway equipment, personnel, and medications whenever pediatric airway management is required

A Coronavirus Disease 2019 Pandemic Pivot: Development of the American Board of Anesthesiology\u27s Virtual APPLIED Examination

In 2020, the coronavirus disease 2019 (COVID-19) pandemic interrupted the administration of the APPLIED Examination, the final part of the American Board of Anesthesiology (ABA) staged examination system for initial certification. In response, the ABA developed, piloted, and implemented an Internet-based virtual form of the examination to allow administration of both components of the APPLIED Exam (Standardized Oral Examination and Objective Structured Clinical Examination) when it was impractical and unsafe for candidates and examiners to travel and have in-person interactions. This article describes the development of the ABA virtual APPLIED Examination, including its rationale, examination format, technology infrastructure, candidate communication, and examiner training. Although the logistics are formidable, we report a methodology for successfully introducing a large-scale, high-stakes, 2-element, remote examination that replicates previously validated assessments