John E. Fiadjoe

A Prospective Randomized Equivalence Trial of the GlideScope Cobalt ® Video Laryngoscope to Traditional Direct Laryngoscopy in Neonates and Infants

Background: Intubation in children is increasingly performed using video laryngoscopes. Many pediatric studies examine novice laryngoscopists or describe single patient experiences. This prospective randomized nonblinded equivalence trial compares intubation time for the GlideScope Cobalt® video laryngoscope (GCV, Verathon Medical, Bothell, WA) with direct laryngoscopy with a Miller blade (DL, Heine, Dover, NH) in anatomically normal neonates and infants. The primary hypothesis was that intubation times with GCV would be noninferior to DL. Methods: Sixty subjects presenting for elective surgery were randomly assigned to intubation using GCV or DL. Intubation time, time to best view, percentage of glottic opening score, and intubation success were documented. We defined an intubation time difference of less than 10 s as clinically insignificant. Results: There was no difference in intubation time between the groups (GCV median = 22.6 s; DL median = 21.4 s; P = 0.24). The 95% one-sided CI for mean difference between the groups was less than 8.3 s. GCV yielded faster time to best view (median = 8.1 s; DL 9.9 s; P = 0.03). Endotracheal tube passage time was longer for GCV (median = 14.3 s; DL 8.5 s; P = 0.007). The percentage of glottic opening score was improved with GCV (median 100; DL 80; P < 0.0001). Conclusions: Similar intubation times and success rates were achieved in anatomically normal neonates and infants with the GCV as with DL. The GCV yielded faster time to best view and better views but longer tube passage times than DL.

Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis

BACKGROUND Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we developed a multicentre registry (Pediatric Difficult Intubation [PeDI]) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications. METHODS The PeDI registry consists of prospectively collected tracheal intubation data from 13 childrens hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe. FINDINGS Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 [28%]), and indirect video laryngoscopy (n=183 [18%]) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication. INTERPRETATION More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety. FUNDING None.

The Pediatric Airway

Abstract This chapter reviews the developmental anatomy and physiology of the pediatric upper airway as it relates to the practice of pediatric anesthesia. Differences between the pediatric and adult airways are important determinants of anesthetic techniques. Knowledge of normal developmental anatomy and physiologic function is required to understand and manage both the normal and the pathologic airways of infants and children. Techniques of mask ventilation, oral and nasal airway placement, use of supraglottic devices, and tracheal intubation are reviewed for normal and anatomically abnormal pediatric patients.

Pediatric Difficult Airway Management: Current Devices and Techniques

The anesthesiologist confronting the difficult pediatric airway is presented with a unique set of challenges. Adult difficult airway management techniques, such as awake or invasive approaches to airway management, often cannot be applied to children because of inadequate cooperation. Consequently, awake intubation in pediatrics is uncommon; most intubations are performed under general anesthesia or deep sedation. From a physiologic perspective, children have higher rates of oxygen consumption, significantly shortening the period of apnea that can be safely tolerated. Normal developmental anatomic differences of the pediatric airway and the presence of craniofacial dysmorphisms, presents additional challenges to tracheal intubation.

The efficacy of the Storz Miller 1 video laryngoscope in a simulated infant difficult intubation.

BACKGROUND: Several studies have shown video laryngoscopy to be a useful technique in the management of patients in whom glottic exposure by direct laryngoscopy is difficult. We conducted this study as a preliminary investigation comparing the Storz DCI Miller 1 video laryngoscope (VL, Karl Storz GmbH, Tuttlingen, Germany) and direct laryngoscopy with a Miller 1 laryngoscope (DL) in an infant manikin model simulating difficult direct laryngoscopy. We hypothesized that compared with DL, VL would provide a better glottic view but would be associated with a longer time to intubation because of the different skill set required when using video intubation. METHODS: A Laerdal® infant airway management training manikin (Laerdal Medical, Wappingers Falls, NY) was adapted using cloth tape to limit cervical spine mobility. Thirty-two attending pediatric anesthesiologists attempted tracheal intubation of the infant manikin using VL and DL in randomized order. The best laryngeal view with each laryngoscope and time to intubation were documented. RESULTS: There was a significant difference in the distributions of laryngoscopy grades between VL and DL (P < 0.001), with the VL giving a better laryngeal view. Forty percent of anesthesiologists reported a Grade 3 or 4 view with DL; all of which were converted to Grades 1 and 2 with VL. The median grade with interquartile range was two (2-3) for DL and one (1-2) for VL (P < 0.001). Seventy-eight percent of participants reported an improvement of at least one grade in laryngeal view with VL compared with DL. There were two failed intubations using DL and none using VL. Time to intubation was similar between the two techniques. CONCLUSIONS: The Storz Miller 1 VL blade improved glottic exposure in a simulated difficult laryngoscopy compared with direct laryngoscopy with a standard Miller 1 blade without increasing the time to intubation.

Reconstituted blood reduces blood donor exposures in children undergoing craniofacial reconstruction surgery

Objective/Aims:  To assess the effect of prophylactic administration of fresh‐frozen plasma (FFP) in the form of reconstituted blood in children undergoing craniofacial reconstruction. The outcomes of interest included immediate postoperative coagulation laboratory test results, postoperative surgical drain output, and the number of unique blood donor exposures incurred.

Telemedicine consultation and monitoring for pediatric liver transplant.

Telemedicine provides the opportunity to bring medical expertise to the bedside, even if the medical expert is not physically near the patient. Internet technology has facilitated telemedicine allowing for voice, video and other data to be exchanged between remote locations. To date, applications of telemedicine to anesthesia (Teleanesthesia) have been limited. Previous work by Cone et al., (Anesth Analg 2006;1463-7) demonstrated the ability to direct an anesthetic in a remote location using satellite communication. In this report, we describe the use of telemedicine to support two cases of elective living related pediatric liver transplants performed at the Narayana Hrudayalaya Institute of Medical Sciences in Bangalore, India with preoperative and intraoperative consultation provided by physicians at the Childrens Hospital of Philadelphia.

Awake laryngeal mask insertion followed by induction of anesthesia in infants with the Pierre Robin sequence

for the discussion. The basic concept of measuring CVP intraoperatively by inserting a CVC is still a hypothesis. Some published studies to date show an appealing association between a low CVP, a low blood loss and a better outcome in patients undergoing elective liver resection. This finding was contradicted in some other studies in which CVP monitoring did not appear to reduce blood loss in elective liver resection. Globally, the intraoperative clinical value of CVP is questionable. Intraoperative changes of transthoracic pressure by both mechanical ventilation and the pressure of surgical retractors on the thorax and right atrium are likely to alter the CVP interpretation. Ascites in a cirrhotic patient is also likely to increase transthoracic pressure hence altering CVP. Furthermore, liver resection has become safer and associated with low intraoperative bleeding mainly because of improved surgical skill and techniques. The evidence that lowering CVP per se decreases blood loss and therefore improves outcome is strong but still circumstantial. To our knowledge, blood loss was demonstrated to be reduced by a low CVP in only one prospective, randomized study of 50 patients. In this study, mean intraoperative blood loss was 2329 ml, a value far above usual blood loss recorded in recent similar series, thus questioning the relevance for the present practice. Furthermore, the causal link between reduced blood loss and improved outcome remains speculative in liver resection similarly as in other surgical fields. Finally, pharmacologic intervention likely to decrease CVP may result in relative hypovolemia, decrease in weak organ vascularization, which has never been convincingly demonstrated to be safe. Many patients undergoing liver resection are old, have coexisting diseases and are likely to have pre-existing organ dysfunction. In this respect, assessing the safety of such practices remains mandatory. In conclusion, a CVC was not contributive in most patients undergoing liver resection in Stephan’s series. However, the clinical contributive value of a low CVP in patients undergoing elective liver resection remains unanswered.

Management of the Difficult Infant Airway with the Storz Video Laryngoscope: A Case Series

The incorporation of video technology into laryngoscopes provides an additional option for the management of difficult intubations. We report the successful use of the Miller 1 Storz Video Laryngoscope in seven infants with difficult direct laryngoscopy.

The air‐Q intubating laryngeal airway in neonates with difficult airways

1 Parameswari A, Vakamudi M, Manickam A et al. Nasal fiberoptic–guided oral tracheal intubation in neonates and infants with Pierre Robin sequence. Pediatr Anesth 2011; 21: 170–171. 2 Xue FS, Luo MP. Management of difficult pediatric airways. In: Xue FS, eds. Modern Airway Management: A Key Technique for Clinical Anesthesia and Critical Care Medicine. Zheng-Zhou: Zheng-Zhou University Publishing House, 2002: 776. 3 Hancock PJ, Peterson G. Finger intubation of the trachea in newborns. Pediatrics 1992; 89: 325–326. 4 Sutera PT, Gordon GJ. Digitally assisted tracheal intubation in a neonate with Pierre Robin syndrome. Anesthesiology 1993; 78: 983–985. 5 Atasay B, Arsan S, Okulu E et al. Hand intubation of a tiny neonate with a large obstructive mass in the oral cavity. Pediatr Anesth 2009; 19: 277–278. 6 Xue FS, Liu JH, Zhang YM et al. The lightwand-guided digital intubation in newborns and infants with difficult airways. Pediatr Anesth 2009; 19: 702–704.