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Background: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first‐attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first‐attempt success rate. Methods: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012–03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings. Results: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First‐attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p =.478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p =.959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: −0.7, 0.7; p =.999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: −0.5, 0.5; p =.999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p =.07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p =.185). Conclusions: Presence of syndrome was not associated with lower first‐attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy. [ABSTRACT FROM AUTHOR]

Background: Management of the pediatric difficult airway can present unique clinical challenges. The Pediatric Difficult Intubation Collaborative (PeDI‐C) is an international collaborative group engaging in quality improvement and research in children with difficult airways. The PeDI‐C established a WhatsApp™ group to facilitate real‐time discussions around the management of the difficult airway in pediatric patients. The goals of this study were to evaluate the patterns of use of the WhatsApp™ group, themes on messages posted on pediatric difficult airway management and to assess the perceived usefulness of the WhatsApp™ group by the PeDI‐C members. Method: Following research ethics approval, we performed a database analysis on the archived discussion of the PeDI‐C WhatsApp™ group from 2014 to 2019 and surveyed members to assess the perceived usefulness of the PeDI‐C WhatsApp™ group. Results: 5781 messages were reviewed with 350 (6.0%) original stems. The three most common original stem types were advice seeking 98 (28%), announcements 85 (24.2%), and clinical case‐sharing 78 (22.2%). The median number of responses to original stems was 9 [2–21.3]. Post types associated with increased responses included those seeking advice on medication/equipment (regression coefficient 0.78, 95% CI [0.41–1.16]; p <.0001); seeking advice on patient care (regression coefficient 1.16, 95% CI [0.86–1.45]; p <.0001), sharing advice on medication/equipment availability (regression coefficient 0.87, 95% CI [0.33–1.40], p <.0016), and clinical case‐sharing (regression coefficient 1.2547, 95% CI [0.9401–1.5693] p <.0001). 46/64 members of the group responded to the survey. Replies offering advice regarding patient management scenarios were found to be of most interest and 77% of surveyed members found the discussion translatable into their own clinical practice. Discussion: The PeDI‐C WhatsApp™ group has facilitated timely knowledge exchange on pediatric difficult airway management across the world. Participants are satisfied with the role the Whatsapp™ group is playing. [ABSTRACT FROM AUTHOR]

The Society for Pediatric Anesthesia launched the Women's Empowerment and Leadership Initiative (WELI) in 2018 to empower highly productive women pediatric anesthesiologists to achieve equity, promotion, and leadership. WELI is focused on six career development domains: promotion and leadership, networking, conceptualization and completion of projects, mentoring, career satisfaction, and sense of well‐being. We sought feedback about whether WELI supported members' career development by surveys emailed in November 2020 (baseline), May 2021 (6 months), and January 2022 (14 months). Program feedback was quantitatively evaluated by the Likert scale questions and qualitatively evaluated by extracting themes from free‐text question responses. The response rates were 60.5% (92 of 152) for the baseline, 51% (82 of 161) for the 6‐month, and 52% (96 of 185) for the 14‐month surveys. Five main themes were identified from the free‐text responses in the 6‐ and 14‐month surveys. Members reported that WELI helped them create meaningful connections through networking, obtain new career opportunities, find tools and projects that supported their career advancement and promotion, build the confidence to try new things beyond their comfort zone, and achieve better work–life integration. Frustration with the inability to connect in‐person during the coronavirus‐19 pandemic was highlighted. Advisors further stated that WELI helped them improve their mentorship skills and gave them insight into early career faculty issues. Relative to the baseline survey, protégés reported greater contributions from WELI at 6 months in helping them clarify their priorities, increase their sense of achievement, and get promoted. These benefits persisted through 14 months. Advisors reported a steady increase in forming new meaningful relationships and finding new collaborators through WELI over time. All the members reported that their self‐rated mentoring abilities improved at 6 months with sustained improvement at 14 months. Thus, programs such as WELI can assist women anesthesiologists and foster gender equity in career development, promotion, and leadership. [ABSTRACT FROM AUTHOR]

Background: There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room. Aim: Our primary aim was to evaluate whether implementation of video laryngoscopy‐guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubation‐associated events. Methods: This is a pre‐post observational study of video laryngoscopy implementation with standardized coaching language for tracheal intubation in a single‐center, pediatric intensive care unit. The use of video laryngoscopy as a coaching device with standardized coaching language was implemented as a part of practice improvement. All patients in the pediatric intensive care unit were included between January 2016 and December 2017 who underwent primary tracheal intubation with either video laryngoscopy or direct laryngoscopy. The uptake of the implementation, sustained compliance, tracheal intubation outcomes including all adverse tracheal intubation‐associated events, oxygen desaturations (<80% SpO2), and first attempt success were measured. Results: Among 580 tracheal intubations, 284 (49%) were performed during the preimplementation phase, and 296 (51%) postimplementation. Compliance for the use of video laryngoscopy with standardized coaching language was high (74% postimplementation) and sustained. There were no statistically significant differences in adverse tracheal intubation‐associated events between the two phases (pre‐ 9% vs. post‐ 5%, absolute difference −3%, CI95: −8% to 1%, p =.11), oxygen desaturations <80% (pre‐ 13% vs. post‐ 13%, absolute difference 1%, CI95: –6% to 5%, p =.75), or first attempt success (pre‐ 73% vs. post‐ 76%, absolute difference 4%, CI95: –3% to 11%, p =.29). Supervisors were more likely to use the standardized coaching language when video laryngoscopy was used for tracheal intubation than with standard direct laryngoscopy (80% vs. 43%, absolute difference 37%, CI95: 23% to 51%, p <.001). Conclusions: Implementation of video laryngoscopy as a supervising device with standardized coaching language was feasible with high level of adherence, yet not associated with an increased occurrence of any adverse tracheal intubation‐associated events and oxygen desaturation. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has disrupted clinician education. To address this challenge, our divisional difficult airway program (AirEquip) designed and implemented small‐group educational workshops for experienced clinicians. Our primary aim was to test the feasibility and acceptability of a small‐group, flexible‐curriculum skills workshop conducted during the clinical workday. Secondary objectives were to evaluate whether our workshop increased confidence in performing relevant skills and to assess the work‐effort required for the new program. Methods: We implemented a 1:1 and 2:1 (participant to facilitator ratio) airway skills workshop for experienced clinicians during the workday. A member of the AirEquip team temporarily relieved the attendee of clinical duties to facilitate participation. Attendance was encouraged but not required. Feasibility was assessed by clinician attendance, and acceptability was assessed using three Likert scale questions and derived from free‐response feedback. Participants completed pre and postworkshop surveys to assess familiarity and comfort with various aspects of airway management. A work‐effort analysis was conducted and compared to the effort to run a previously held larger‐format difficult airway conference. Results: Fifteen workshops were conducted over 7 weeks; members of AirEquip were able to temporarily assume participants' clinical duties. Forty‐seven attending anesthesiologists and 17 CRNAs attended the workshops, compared with six attending anesthesiologists and five CRNAs who attended the most recent larger‐format conference. There was no change in confidence after workshop participation, but participants overwhelmingly expressed enthusiasm and satisfaction with the workshops. The number of facilitator person‐hours required to operate the workshops (105 h) was similar to that required to run a single all‐day larger‐format conference (104.5 h). Conclusion: It is feasible and acceptable to incorporate expert‐led skills training into the clinical workday. Alongside conferences and large‐format instruction, this modality enhances the way we are able to share knowledge with our colleagues. This concept can likely be applied to other skills in various clinical settings. [ABSTRACT FROM AUTHOR]

Background: The authors recognized a gap in existing guidelines and convened a modified Delphi process to address novel issues in pediatric difficult airway management raised by the COVID‐19 pandemic. Methods: The Pediatric Difficult Intubation Collaborative, a working group of the Society for Pediatric Anesthesia, assembled an international panel to reach consensus recommendations on pediatric difficult airway management during the COVID‐19 pandemic using a modified Delphi method. We reflect on the strengths and weaknesses of this process and ways care has changed as knowledge and experience have grown over the course of the pandemic. Recommendations: In the setting of the COVID‐19 pandemic, the Delphi panel recommends against moving away from the operating room solely for the purpose of having a negative pressure environment. The Delphi panel recommends supplying supplemental oxygen and using videolaryngoscopy during anticipated difficult airway management. Direct laryngoscopy is not recommended. If the patient meets extubation criteria, extubate in the OR, awake, at the end of the procedure. Reflection: These recommendations remain valuable guidance in caring for children with anticipated difficult airways and infectious respiratory pathology when reviewed in light of our growing knowledge and experience with COVID‐19. The panel initially recommended minimizing involvement of additional people and trainees and minimizing techniques associated with aerosolization of viral particles. The demonstrated effectiveness of PPE and vaccination at reducing the risk of exposure and infection to clinicians managing the airway makes these recommendations less relevant for COVID‐19. They would likely be important initial steps in the face of novel respiratory viral pathogens. Conclusions: The consensus process cannot and should not replace evidence‐based guidelines; however, it is encouraging to see that the panel's recommendations have held up well as scientific knowledge and clinical experience have grown. [ABSTRACT FROM AUTHOR]

Background: To improve pediatric airway management outside of the operating room, a Hospital‐wide Emergency Airway Response Team (HEART) program composed of anesthesiology, otorhinolaryngology, and respiratory therapy clinicians was developed. Aims: To report processes and outcomes of HEART activations in a quaternary academic children's hospital. Methods: A retrospective observational cohort study between January 2017 and December 2019. Local airway emergency database was reviewed for HEART activations. Additional safety data was obtained from patients' electronic health records. Primary outcome: Adverse airway outcomes, either adverse tracheal intubation‐associated events or oxygen desaturation (SpO2 <80%). We compared airway management by primary teams before HEART arrival and by HEART after arrival. Results: Of 96 HEART activations, 36 were from neonatal intensive care unit, 35 from pediatric and cardiac intensive care units, 14 from emergency department, and 11 from inpatient wards. 56 (62%) children had airway anomalies and 41/96 (43%) were invasively ventilated. Median HEART arrival time was 5 min (interquartile range, 3–5). 56/96 (58%) required insertion of an advanced airway (supra/extra‐glottic airway, endotracheal tube, tracheostomy tube). HEART succeeded in establishing a definitive airway in 53/56 (94%). Adverse airway outcomes were more common before (56/96, 58%) versus after HEART arrival (28/96, 29%; absolute risk difference 29%; 95% confidence interval 16, 41%; p <.001). Oxygen desaturation occurred more frequently before (46/96, 48%) versus after HEART arrival (24/96, 25%; absolute risk difference 23%; 95% confidence interval 11, 35%; p =.02). Cardiac arrests were more common before (9/96, 9%) versus after HEART arrival (3/96, 3%). Multiple (≥3) intubation attempts were more frequent before (14/42, 33%) versus after HEART arrival (9/46, 20%; absolute risk difference −14%; 95% confidence interval −32, 5%; p =.15). Conclusions: A multidisciplinary emergency airway response team plays an important role in pediatric airway management outside of the operating room. Adverse airway outcomes were more frequent before compared to after HEART arrival. [ABSTRACT FROM AUTHOR]

Scientific presentations, usually given with slide presentation software such as PowerPoint™, are the most common method for disseminating knowledge to students and peers. Unfortunately, many are boring, text‐heavy, and bullet point–riddled data dumps, with animations or cartoons that obscure or distract rather than clarify the message. These presentations, which we have all sat through and/or delivered, are often so dull that they are referred to as "death by PowerPoint™." In this paper, the authors intend to impart basic techniques for organizing and communicating information in the most effective, engaging, and actionable ways possible. We focus on three processes: generating ideas and outlining a talk, creating visually appealing uncluttered slides, and delivering an inspiring, practice‐changing presentation. We also discuss considerations for a virtual presentation. We believe that even experienced speakers could benefit from reflecting on these recommendations and editing their slide presentations for clarity and simplicity. [ABSTRACT FROM AUTHOR]

Promoting and retaining junior faculty are major challenges for many medical schools. High clinical workloads often limit time for scholarly projects and academic development, especially in anesthesiology. To address this, we created the East/West Visiting Scholars in Pediatric Anesthesia Program (ViSiPAP). The program's goal is to help "jumpstart" academic careers by providing opportunities for national exposure and recognition through invited lectures and collaborative opportunities. East/West ViSiPAP benefits the participating scholars, the home and hosting anesthesia departments, and pediatric anesthesia fellowship training programs. By fostering a sense of well‐being and inclusion in the pediatric anesthesia community, East/West ViSiPAP has the potential to increase job satisfaction, help faculty attain promotion, and reduce attrition. Faculty and trainees are exposed to new expertise and role models. Moreover, ViSiPAP provides opportunities for women and underrepresented in medicine faculty. This program can help develop today's junior faculty into tomorrow's leaders in pediatric anesthesia. We advocate for expanding the concept of ViSiPAP to other institutions in academic medicine. [ABSTRACT FROM AUTHOR]

Neonatal airway emergencies in the delivery room are associated with significant morbidity and mortality. Etiologies vary, but often predispose the neonate to life threatening airway obstruction. With the recent expansion of fetal medicine programs, pediatric anesthesiologists are increasingly being asked to care for these patients. In this review, we discuss common etiologies of difficult airway at delivery, management tools and techniques, and surgical approaches. [ABSTRACT FROM AUTHOR]

Background: Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit. Methods: Expert review of the recent literature. Results: Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation–associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration. Conclusion: Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings. [ABSTRACT FROM AUTHOR]

Background: Children routinely undergo inhalational induction of general anesthesia. Intravenous line placement typically occurs after induction of anesthesia and can be challenging, particularly in infants and young children. Aims: We conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. The secondary aim was to identify factors associated with multiple attempts to insert intravenous lines. Methods: After institutional research board approval, we retrieved a data set of all children between 0 months and 18 years who received general anesthesia at our hospital between January 1, 2016, and September 30, 2017. Data included age, gender, weight, race, ASA status, gestational age, number of peripheral intravenous catheter insertion attempts, any assistive device for insertion, and insertion site. Inclusion criteria were mask induction, ASA status 1 or 2, nonemergency, ambulatory surgical procedures, and placement of a single intravenous line during the anesthetic. Results: A total of 9693 patients were included in the study. Of which 8869 patients required one insertion attempt and 824 underwent multiple insertion attempts. 50% of patients in the single insertion attempt group had clear liquid fasting time <6.9 hours compared to 51.8% of patients requiring multiple attempts. Logistic regression model adjusted for age, ASA status, gender, and BMI did not find an association between duration of clear liquid fasting time and rate of multiple insertion attempts for intravenous catheters (OR: 0.99, 95% CI: 0.98‐1.01, P =.47). Conclusion: Clear liquid fasting time was not associated with multiple insertion attempts for intravenous line insertion in children receiving general anesthesia. Factors such as patient age, ethnicity, time of day of induction of anesthesia, and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts. [ABSTRACT FROM AUTHOR]

Summary: 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. [ABSTRACT FROM AUTHOR]

Ultrasound technology is available in many pediatric perioperative settings. There is an increasing number of ultrasound applications for anesthesiologists which may enhance clinical performance, procedural safety, and patient outcomes. This review highlights the literature and experience supporting focused ultrasound applications in the pediatric perioperative setting across varied disciplines including anesthesiology. The review also suggests strategies for building educational and infrastructural systems to translate this technology into clinical practice. [ABSTRACT FROM AUTHOR]

Background Although it is known that a patient's race may influence their medical care, racial patterns of medication administration in pediatric anesthesia have not been well-studied. The aim of this study was to determine if differences exist between Black and White children with regard to administration of anesthetic and analgesic medications for a single procedure at our institution. Methods We conducted a retrospective review of medications administered to patients for emergency appendectomies at a large academic children's hospital from 2010 to 2015. We examined the association between patient race and administration of preoperative midazolam and intraoperative ondansetron, lidocaine, ketorolac, and weight-based doses of fentanyl and morphine. Results During the study period, 1680 patients (1329 White, 351 Black) underwent emergency appendectomy. There were no significant racial differences in administration of intraoperative anesthetic medications between Black and White children. In unadjusted analysis, Black children were less likely to receive preoperative midazolam than White children ( OR=0.74 [95% CI, 0.58-0.94], P=.012). After adjusting for confounders, there was no evidence of racial differences in administration of preoperative or intraoperative medications. Conclusion We did not find a significant difference in preoperative or intraoperative medication administration based on race when we adjusted for age, gender, and attending anesthesiologist practice patterns. We encourage all institutions to monitor their own practice patterns with regard to race. [ABSTRACT FROM AUTHOR]

Background Antifibrinolytic therapy significantly decreases blood loss and transfusion in pediatric cranial vault reconstructive surgery; however, concern regarding the side effects profile limits clinical use. Aims The aim was to utilize the Pediatric Craniofacial Surgery Perioperative Registry database to identify the safety profile of antifibrinolytic therapy for cranial vault reconstructive surgery by reporting the incidence of adverse events as they relate to exposure to tranexamic acid and aminocaproic acid compared to no exposure to antifibrinolytics. Methods The database was queried for cases of open cranial vault reconstructive surgery. Less invasive procedures such as neuro-endoscopic and spring-mediated cranioplasties were excluded. The outcomes evaluated included any perioperative neurological adverse event including seizures or seizure-like movements and thromboembolic events. Results Thirty-one institutions reported a total of 1638 cases from 2010 to 2015. Total antifibrinolytic administration accounted for 59.5% (tranexamic acid, 36.1% and aminocaproic acid, 23.4%), with 40.5% not receiving any antifibrinolytic. The overall incidence of postoperative seizures or seizure-like movements was 0.6%. No significant difference was detected in the incidence of postoperative seizures between patients receiving tranexamic acid and those receiving aminocaproic acid [the odds ratio for seizures being 0.34 (95% confidence interval: 0.07-1.85) controlling for American Society of Anesthesia (ASA) physical class] nor in patients receiving antifibrinolytics compared to those not administered antifibrinolytics (the odds ratio for seizures being 1.02 (confidence interval 0.29-3.63) controlling for ASA physical class). One complicated patient in the antifibrinolytic group with a femoral venous catheter had a postoperative deep venous thrombosis. Conclusions This is the first report of an incidence of postoperative seizures of 0.6% in pediatric cranial vault reconstructive surgery. There was no significant difference in postoperative seizures or seizure-like events in those patients who received the tranexamic acid or aminocaproic acid vs those that did not. This report provides evidence of the safety profile of antifibrinolytic in children having noncardiac major surgery. Caution should prevail however in using antifibrinolytic in high-risk patients. Antifibrinolytic dosage regimes should be based on pharmacokinetic data avoiding high doses. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The definition of extubation failure should also be clear: Does extubation fail if one needs supportive measures such as noninvasive ventilation, or is it simply the need for reintubation? Keywords: airway; complications; extubation; intubation; pediatric anesthesia EN airway complications extubation intubation pediatric anesthesia 590 591 2 04/26/22 20220501 NES 220501 Daniel Kahneman, a psychologist and Nobel laureate, conducted a fascinating study of patients undergoing colonoscopy and found that discomfort at the end of the procedure played a larger role in their perceptions of pain than the total pain experienced. Therefore, we encourage researchers to focus on determining best practices around extubation and encourage the development of pediatric-specific extubation guidelines and checklists.5 In this regard, the R2D2 framework could inspire the creation of a difficult extubation checklist. [Extracted from the article]

Background The GlideScope Cobalt Video laryngoscope is being used more often in children with challenging laryngoscopy. There are, however, no pediatric trials comparing it to flexible fiberoptic bronchoscopy, the current accepted gold standard. This preliminary manikin study compares the first-attempt intubation success of the GlideScope Cobalt video laryngoscope to the flexible fiberoptic bronchoscope when performed by attending pediatric anesthesiologists at two major pediatric centers. Methods This prospective randomized, crossover study evaluated 120 attempts (60 with each study device) to intubate the AirSim Pierre Robin manikin (PRM) with fiberoptic bronchoscopy and video laryngoscopy (VL). Attending pediatric anesthesiologists from two quaternary pediatric centers were eligible to participate. Each attending anesthesiologist randomly performed a single tracheal intubation attempt with one of the study devices followed by the alternate method. The primary outcome was the first-attempt success rate of tracheal intubation. Blinding was not feasible. We hypothesized that first-attempt success would be higher with fiberoptic bronchoscopy. Results Thirty anesthesiologists from each center were randomized to use one of the study devices followed by the alternate method. We analyzed all participants' data. There was no overall difference in first-attempt success between VL and fiberoptic bronchoscopy (88.3% vs 85% respectively, P = 0.59). There were significant institutional differences in first-attempt success using VL (76.7% vs 100%). Conclusions There was no difference in first-attempt success of tracheal intubation using VL vs fiberoptic bronchoscopy when performed by attending anesthesiologists at two large pediatric centers. However, institutional differences exist in success rates with VL across the two centers. Results from single-center device evaluations should be verified by multi-center evaluations. A significant proportion of attending anesthesiologists lack experience with advanced airway devices; targeted education may enhance intubation success and patient safety. [ABSTRACT FROM AUTHOR]

Summary Objective/Aims: To assess current practices in the management of children undergoing craniofacial surgery and identify areas of significant practice variability with the intent to direct future research. Background: The perioperative management of infants and children undergoing craniofacial reconstruction surgery can be challenging because of the routine occurrence of significant blood loss with associated morbidity. A variety of techniques have been described to improve the care for these children. It is presently unknown to what extent these practices are currently employed. Methods: A web-based survey was sent to representatives from 102 institutions. One individual per institution was surveyed to prevent larger institutions from being over-represented in the results. Results: Requests to complete the survey were sent to 102 institutions; 48 surveys were completed. The survey was composed of two parts: management of infants undergoing strip craniectomies, and management of children undergoing major craniofacial reconstruction. Conclusions: Significant variability exists in the management of children undergoing these procedures; further study is required to determine the optimal management strategies. Clinical trials assessing the utility of central venous pressure and other hemodynamic monitoring modalities would enable evidence-based decision-making for monitoring in these children. The development of institutional transfusion thresholds should be encouraged, as there exists a body of evidence supporting their efficacy and safety. [ABSTRACT FROM AUTHOR]

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. We recently changed our intraoperative transfusion strategy in children undergoing craniofacial reconstruction surgery to one in which blood loss is replaced with donor-matched reconstituted blood rather than traditional blood component therapy. We performed a query of our prospective craniofacial surgery perioperative registry for children who underwent fronto-orbital advancement or posterior cranial vault reconstruction. Registry data from this query were compared to data from a historical cohort. Data for 46 registry cases were compared to 150 historical cohort cases. The median number of unique donor exposures for the reconstituted blood group was 2 vs 3 in the historical cohort ( P = 0.004). The reconstituted blood group had a decreased incidence of postoperative derangements in soluble clotting factor tests (fibrinogen, PT, or aPTT; 2% vs 24%, P = 0.001), while there was no evidence for a difference in the incidence of thrombocytopenia. There was no evidence for differences in postoperative surgical drain output in the reconstituted blood group and historical cohort over the first 12, 24, and 48 h. Prophylactic administration of FFP in the form of donor-matched reconstituted blood in children undergoing craniofacial reconstruction was associated with improved postoperative coagulation parameters, reduced blood donor exposures, and unchanged postoperative surgical drain output. [ABSTRACT FROM AUTHOR]

When a pilot balloon fails or is an impediment to an intubation, such as via a pediatric laryngeal mask, options are generally limited to a tracheal tube exchange. Simple and effective solutions are described to replace a pilot balloon in a variety of clinical situations by using equipment that is readily available in operating rooms. Equipment such as intravenous catheters or epidural clamp connectors provides reliable, light weight, and streamlined substitutions for pilot balloons when connected to the pilot-cuff inflation line. [ABSTRACT FROM AUTHOR]

Sir, The COVID-19 pandemic has transformed care in operating rooms and healthcare centers. A nasopharyngeal swab was performed to test for COVID-19 (PCR-based test) as per our institution's standard practice but because of the emergent nature of his surgery the COVID-19 test result was not available before anesthesia induction. Screening with questions about cough, fever, and travel may not identify children with COVID-19, and centers should consider testing to determine children's COVID-19 status. [Extracted from the article]

A letter to the editor is presented in response to the article "Are new supraglottic airway devices, tracheal tubes and airway viewing devices cost-effective?," by S. J. Slinn and colleagues in the 2015 issue.

A letter to the editor is presented regarding the case of a seven month-old boy with congenital bilateral ptosis who underwent a video laryngoscopy.

The authors reflect on a case report with regards to the tension pneumothorax and its resultant cardiac arrest following the oxygen administration through a fiberoptic bronchoscope. Topics discussed include an overview of the case report, the methodology used in the study and its outcomes, and its potential human error.

A letter to the editor is presented in response to the article on the performance of the Bonfils fiberscope to the GlideScope Cobalt videolaryngoscopes in children less than seven years old.

A letter to the editor is presented in response to the article regarding the evaluation of the air-Q as an intubation conduit in infants by Sinha and colleagues.

A letter to the editor is presented in response to the article "Factors influencing blood loss and allogeneic blood transfusion practice in craniosynostosis surgery," by A. van Uitert, J. H. Megens, and C. C. Breugem in a 2011 issue.

A letter to the editor is presented in response to the article "Retrospective audit of the air-Q intubating laryngeal airway as a conduit for tracheal intubation in pediatric patients with a difficult airway," by N. Jagannathan and colleagues in the 2011 issue.

A letter to the is presented in response to the article regarding the technique of reverse loading of the tracheal tube during blind intubation.

A letter to the editor is presented on the use of the air-Q as a conduit for fiberoptic tracheal intubation in infants.

A letter to the editor is presented in response to the article on video laryngoscopy in children which was published in the previous issue.

A letter to the editor is presented about the treatment of severe hemorrhage during the craniofacial surgery in infant.

A letter to the editor is presented in response to the articles "Laryngeal mask airway and difficult airway management in adolescent: a case report," by M. Oofuvong and colleagues in the 2008 issue and "Measures to facilitate the classic laryngeal mask airway guided fiberoptic intubation in children with a difficult airway," by FS Xue and colleagues in the 2008 issue.

A letter to the editor is presented in response to the article "Continuous monitoring of dynamic pulmonary compliance enables detection of endobronchial intubation in infants and children," by A. Mahajan and colleagues, in a 2007 issue.

A letter to the editor is presented in response to the article "Glossopharyngeal Nerve Blocks for Awake Laryngeal Mask Airway Insertion in an Infant With Pierre-Robin Syndrome: Can a Glidescope Come to the Rescue?," by N. Jagannathan, L.E. Sohn and S. Suresh published in a previous issue.