Maria Matuszczak

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.

Continuous posterior lumbar plexus block for acute postoperative pain control in young children.

A 60-yr-old man, 160 cm tall, weighing 75 kg, with American Society of Anesthesiologists physical status class II, was admitted for elective right shoulder surgery. His medical history was unremarkable except for recent mild diabetes with no related neuropathy, controlled by diet and glimepiride. Physical examination results were unremarkable, and the results of laboratory studies were all within normal limits, including preoperative glycemia and chest x-ray. He agreed to undergo a combination of regional and general anesthesia. Hydroxyzine, 100 mg, was administered 2 h preoperatively. After application of routine monitors, intravenous access was secured. He was positioned supine with the head turned to the contralateral side, and the right side of the neck was prepared as a sterile field. The elbow was flexed, with the forearm lying on the patient’s abdomen. Thereafter, interscalene brachial plexus block was performed as described by Winnie but using a nerve stimulator to ascertain that the needle’s tip was in the brachial plexus. The plexus was located with a nerve stimulator (Stimuplex HNS 11; B/Braun, Melsungen, Germany) and an insulated needle, 25 mm long with a short 30° bevel (Stimuplex, B/Braun). Three attempts at needle insertion were required to achieve an appropriate motor response: the brachial plexus was first located using a high current intensity (2 mA; 0.1 ms and 1 Hz), and then it was decreased to 0.5 mA to refine the approach. After obtaining a motor response of the deltoid muscle, a mixture of 30 ml ropivacaine, 0.75%, and 75 g clonidine was injected. No blood could be aspirated, and the patient reported neither pain nor paresthesia during the procedure, although phrenic nerve stimulation was transiently observed. After 20 min, profound surgical anesthesia was established on C5–C7 dermatomes. Then, general anesthesia was induced with 2 mg midazolam, 100 g fentanyl, 200 mg propofol, and 30 mg atracurium to facilitate tracheal intubation. General anesthesia was maintained with 1–2% sevoflurane and 50% nitrous oxide, and the patient underwent a right rotator cuff repair via a deltopectoral approach. He was placed in a “beach chair” position with his head turned the opposite direction. Vital signs and standard parameters remained stable throughout the 2-h procedure. At the end of surgery, the trachea was extubated, and the patient was observed for 1 h in the postanesthesia care unit. He did not report any pain. Vital signs and postoperative glycemia were normal. The interscalene brachial plexus blockade was still effective. Postoperative analgesia consisted of regular administration of a combination of propacetamol and nefopam intravenously. The patient was discharged to the ward. Postoperative follow-up was unremarkable. Ten days later, the patient was readmitted to the hospital because of increasing shortness of breath. A chest roentgenogram revealed marked elevation of the right hemidiaphragm when compared with the preoperative chest film. No signs of infection or other disorders were shown on the film. This pattern was suggestive of acquired phrenic nerve palsy. Because the moderate difficulty in breathing persisted despite physiotherapy, a complete checkup was made 3 months after the block. A new chest x-ray confirmed that the elevation of the right hemidiaphragm was unchanged and revealed atelectasis limited to the lower part of the right lung field, probably related to the right ventilatory deficit. No movement of the hemidiaphragm was observed during fluoroscopy, and paradoxical motion was shown by sniffing maneuver. Pulmonary function tests showed mild restrictive lung disease: vital capacity, forced expiratory volume in 1 s, forced vital capacity, and total lung capacity were respectively reduced to 89, 79, 88, and 76% of predicted values. By contrast, peak expiratory flow rate, arterial oxygen tension (PaO2), and arterial carbon dioxide tension (PaCO2) were in the normal range. Computed tomography and nuclear magnetic resonance scans of the neck and thorax were also normal. A definitive diagnosis of phrenic nerve dysfunction as the cause of hemidiaphragm paralysis was obtained by electromyography using phrenic nerve stimulation in the neck and the measurements of phrenic nerve latencies and conduction velocities. Stimulating electrodes were placed over the phrenic nerve in the supraclavicular fossa. The compound action potential of the hemidiaphragm was recorded using surface electrodes placed on the anterolateral aspect of the chest in the seventh intercostal space in the anterior axillary line. Results showed the absence of a right phrenic nerve compound action potential, whereas the left phrenic nerve conduction velocity was normal, suggesting that the right phrenic nerve was completely interrupted or significantly demyelinated. Although this examination failed to identify the mechanism or the precise location of the lesion, it was useful in confirming the lack of electromyographic pattern of diffuse neuropathy. One year after surgery, the patient still reported exertional dyspnea with no functional improvement.

A prospective, randomized comparison of cobra perilaryngeal airway and laryngeal mask airway unique in pediatric patients

BACKGROUND: The Cobra Perilaryngeal Airway (PLA) provides better sealing pressure than the Laryngeal Mask Airway Unique (LMAU) during positive-pressure ventilation in adults. We compared the performance of the CobraPLA and LMAU in infants and children. METHODS: Two-hundred pediatric patients were randomly assigned to a CobraPLA or an Laryngeal Mask Airway (LMA). We measured airway sealing at cuff inflation pressures of 40 and 60 cm H2O; ease and time of insertion; device stability; efficacy of ventilation; number of insertion attempts; incidence of postoperative sore throat, dysphonia, laryngospasm, bronchospasm, and gastric gas insufflation. Steady-state end-tidalCO2 was measured at the head of the CobraPLA and at the “Y-piece” piece of the anesthetic circuit. For the major outcomes, the airway groups were subdivided post hoc into small and large CobraPLA and small and large LMA subgroups. Results are presented as means ± sds; P < 0.05 was considered statistically significant. RESULTS: Airway sealing pressure with the cuff inflated to 60 cm H2O in the large CobraPLA subgroup (22 ± 7 cm H2O) was significantly more than that of the small CobraPLA subgroup (18 ± 5 cm H2O) and large LMA subgroup (16 ± 5 cm H2O; P < 0.001). The CobraPLA was more stable than the LMA (same anatomic fit score before and after surgery) and produced less gastric insufflation. Head CobraPLA end-tidalCO2 values were 6.4 ± 6 mm Hg more than those of the Y piece of the circle circuit. CONCLUSIONS: The CobraPLA airway performed as well as the LMAU during anesthesia in pediatric patients for a large range of outcomes and was superior for some.

Caudal Regional Anesthesia, Ropivacaine Concentration, Postoperative Analgesia, and Infants

In this randomized, double-blind trial we evaluated the quality and duration of analgesia and motor effects after caudal block using 1 mL/kg of ropivacaine 0.1% (Group 1), 0.15% (Group 2), 0.175% (Group 3) compared to 0.2% (Group 4) in infants 1–12 mo old. Postoperatively, the number of infants who received pain medication differed among the groups (P < 0.0005). There were more infants in Groups 1 and 2 compared with Group 4 and there was no difference between Groups 3 and 4. In the postanesthesia care unit, infants in Groups 1 and 2 received more pain medication than did those in Group 4 (P = 0.0098). In the day surgery unit, there was a significant difference among the groups (P = 0.0326); infants in Groups 3 and 4 required no pain medication. The analgesia duration differed among the groups (P = 0.034). Infants in Groups 1 and 2 had a shorter duration, and there was no difference between Groups 3 and 4. Infants in Group 4 took longer to regain their motor power compared with those in Group 3 (P = 0.0347). We conclude that in infants, ropivacaine 0.175% provided postoperative analgesia and duration similar to that of ropivacaine 0.2%, whereas ropivacaine 0.1% and 0.15% did not, and it was associated with fewer motor effects.

Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy

Background:  There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single‐blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia.

Sciatic nerve blocks

Sciatic nerve blocks are infrequently performed by anesthesiologists. These blocks are considered to be more difficult, and they require the use of long needles, causing apprehension to both the patient and the anesthesiologist. However, the use of nerve stimulators significantly facilitates the approach of the sciatic nerve. The nerve can essentially be blocked either high or at the popliteal fossa (popliteal block) before or at its division. Although surgery of the lower extremity does not necessarily require sciatic nerve conduction to be blocked, when indicated, this is a very effective method for controlling pain and reducing the length of hospitalization, the latter leading to substantial savings. Different approaches have been described (eg, posterior, anterior and lateral). Each approach has specific indications that need to be recognized. Consequently it is necessary to be familiar with more than one approach. Thus, a parasacral or classic posterior approach of the sciatic nerve is recommended in lateral positions, whereas the anterior approach is favored in the supine patient. When the strategy of anesthesia is developed or the placement of a catheter is considered, it is important to recognize that sciatic blocks have the slowest onset and longest duration compared with all other peripheral nerve blocks performed by anesthesiologists. For single injections in adults, our preference is a combination of 1.5% lidocaine and 0.75% ropivacaine (equivolumes) with the addition of bicarbonate and epinephrine for a total volume of 20 to 30 mL in adults.

Correspondence Letter to the Editor regarding 'The presumed central nervous system effects of rocuronium in a neonate and its reversal with sugammadex' by Langley, McFadzean & McCormack.

on perioperative outcomes. The complexities of ASD create challenges for research that will require creative solutions and additional resources. Answers to some of the challenges can already be found in the broader ASD literature. For example, there are standardized tools for characterizing autism symptoms and adaptive functioning, and concerns about diagnosis before and after the publication of the DSM-5 have been addressed. Some might inadvertently assume that Ross’s (3) editorial suggests that our hands are tied and we have to accept the absence of evidence-based information. We caution against this interpretation. Investigators have only just turned attention to this issue and it would seem a shame to quit before we have begun. Instead, let us untie our hands and begin the important work of establishing an evidence base upon which to improve clinical practice.