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Management of narrowed airways can be challenging, especially in the smallest patients. This educational review focusses on active expiration through small-bore airways with the Ventrain (Ventinova Medical, Eindhoven, The Netherlands). Manual ventilation with the Ventrain establishes inspiratory and expiratory flow control: By setting an appropriate flow, the volume of gas insufflated over time can be controlled and expiration through a small-bore airway is expedited by jet-flow generated suction, coined "expiratory ventilation assistance" (EVA). This overcomes the inherent risks of emergency jet ventilation especially in pediatric airway emergencies. Active expiration by EVA has been clinically introduced to turn a "straw in the airway" into a lifesaver allowing not only for quick and reliable reoxygenation but also adequate ventilation. As well as managing airway emergencies, ventilating through small-bore airways by applying EVA implements new options for pediatric airway management in elective interventional procedures. Safe application of EVA demands a thorough understanding of the required equipment, the principle and function of the Ventrain, technical prerequisites, clinical safety measures, and, most importantly, appropriate training.

Posterior fossa decompression for Chiari I Malformation is a common pediatric neurosurgical procedure. We sought to identify the impact of anesthesia-related intraoperative complications on unanticipated admission to the intensive care unit and outcomes following posterior fossa decompression.Medical records of all patients18 years who underwent surgery for Chiari I malformation between 1/1/09 and 1/31/21 at the AnnRobert H. Lurie Children's Hospital of Chicago were included. Records were reviewed for patient characteristics, anesthesia-related intraoperative complications, postoperative complications, and surgical outcomes. The primary outcome was the incidence of unanticipated admission to the intensive care unit, and the primary variable of interest was an anesthesia-related intraoperative complication. Patient, surgical characteristics, and year of surgery were also compared between patients with and without an unanticipated admission to the intensive care unit, and a multi-variable adjusted estimate of odds of unanticipated admission to the intensive care unit admission following an anesthesia-related intraoperative complication was performed. Secondary outcomes included anesthesia factors associated with an anesthesia-related intraoperative event, and postoperative complications and surgical outcomes between patients admitted to the intensive care unit and those who were not.Two hundred ninety-six patients with Chiari I Malformation were identified. Clinical characteristics associated with an unanticipated admission to the intensive care unit were younger age, American Society of Anesthesiologist (ASA) physical status2 and an anesthesia-related intraoperative complication. 29 anesthesia-related intraoperative complications were observed in 25 patients (8.4%). Two of 25 patients (8%) with an anesthesia-related intraoperative complication compared with 3 of 271 (1%) patients without anesthesia-related intraoperative complication had an unanticipated admission to the intensive care unit, odds ratio 7.8 (95% CI 1.2-48.8, p = .010). When adjusted for age, sex, ASA physical status, presenting symptoms, concomitant syringomyelia, previous decompression surgery and year of surgery, the odds ratio for an unanticipated admission to the intensive care unit following an anesthesia-related intraoperative complication was 5.9 (95% CI 0.51-59.6, p = .149). There were no differences in surgical outcomes between patients with or without an unanticipated admission to the intensive care unit.Our study demonstrates that although anesthesia-related intraoperative complications during posterior fossa decompression are infrequent, they are associated with an increased risk of an unanticipated admission to the intensive care unit.

Airway endoscopy (rigid and flexible bronchoscopy) is an important procedure that allows for visualization of the trachea and bronchi as well as treatment of a variety of airway disorders for diagnostic and therapeutic interventions. Excellent communication between the anesthesiologist and the endoscopist is required to ensure that adequate oxygenation and ventilation is maintained via the shared airway. Various anesthetic and airway management techniques can be used for airway management in pediatric foreign-body aspiration. This article highlights indications, techniques, and complications encountered during pediatric bronchoscopy, with particular focus on anesthetic management of the pediatric airway.

Background Preoperative pulmonary function tests are routinely obtained in children with scoliosis undergoing posterior spinal fusion despite unclear benefits as a perioperative risk assessment tool and frequent inability of patients to provide acceptable results. The goal of this study was to determine whether preoperative pulmonary function test results are associated with the need for postoperative intubation or intensive care unit admission after posterior spinal fusion. Methods The electronic medical records of patients who underwent posterior spinal fusion at a pediatric tertiary hospital between June 2012 and August 2017 were reviewed. Pulmonary function tests were consistently ordered for all patients, unless the patient was deemed unable to perform the test due to cognitive disability. Cases were categorized as primary or secondary scoliosis.Demographic data, preoperative bilevel positive airway pressure use, Cobb angle, intraoperative allogeneic blood transfusion, and ability to produce acceptable pulmonary function test results were collected for each patient. In patients with satisfactory pulmonary function test results, forced vital capacity and maximum inspiratory pressure were collected. Primary outcomes for analysis were postoperative intubation and intensive care unit admission. Univariable logistic regression models were used to assess the association between each variable of interest and the primary outcomes. Results The study sample included 433 patients, 288 with primary scoliosis and 145 with secondary scoliosis. Among patients with primary scoliosis, 90% were able to produce acceptable pulmonary function test results, zero remained intubated postoperatively, and 6 were admitted to the intensive care unit. Among patients with secondary scoliosis, 44% could not attempt pulmonary function tests. Among those who did attempt the test, 30% were unable to produce meaningful results. Forced vital capacity and maximum inspiratory pressure were not found to be associated with postoperative intubation or intensive care unit admission. Weight, Cobb angle, intraoperative blood transfusion, American Society of Anesthesiologists physical status classification, and preoperative bilevel positive airway pressure use were associated with patient outcomes. Among 357 total patients who attempted pulmonary function tests, 37 had high-risk results. Only 1 of these 37 patients remained intubated postoperatively. Conclusions Patients undergoing posterior spinal fusion, especially those with secondary scoliosis, are frequently unable to adequately perform pulmonary function tests. Among patients with interpretable pulmonary function tests, there was no association between results and postoperative intubation or intensive care unit admission. Routine pulmonary function testing for all patients with scoliosis may not be indicated for purposes of risk assessment before posterior spinal fusion. Clinicians should consider a targeted approach and limit pulmonary function tests to patients for whom results may guide preoperative optimization as this may improve outcomes and reduce inefficiencies and costs.

Difficult airway management in children is associated with significant morbidity. This narrative review on error traps in airway management aims to highlight the common pitfalls and proposes solutions to optimize best practices for pediatric difficult airway management. We have categorized common errors of pediatric difficult airway management into three main error traps: preparation, performance, and proficiency, and present potential strategies to improve patient safety and successful tracheal intubation in infants and children with difficult airways.

Patients with Pierre Robin sequence present with numerous anatomical abnormalities that make mask ventilation and tracheal intubation challenging. In this case series, we describe a unique way to overcome upper airway obstruction with the placement of a supraglottic airway in 4 children with Pierre Robin sequence followed by flexible bronchoscopic nasotracheal intubation. This new approach is proven to be a successful method to overcome severe upper airway obstruction, provide continuous oxygenation, and allows nasotracheal intubation for intraoral procedures.

Background There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity. Methods Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms “general anesthesia and neurodevelopment” as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence. Results In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures. Conclusion There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist. Type of study Systematic review of level 1–4 studies. Level of evidence Level 1–4 (mainly level 3–4)

Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation are rare neurocristopathies characterized by autonomic dysregulation including bradyarrhythmias, abnormal temperature control, and most significantly, abnormal control of breathing leading to tracheostomy and ventilator dependence as life support. Surgical advancements have made phrenic nerve-diaphragm pacemakers available, to eliminate the tether to a mechanical ventilator for 12-15 hours each day. The thoracoscopic approach to implantation has allowed for a less invasive approach which may have implications for pain control and recovery time. However, thoracoscopic implantation of these devices presents several challenges to the anesthesiologist in these complex ventilator-dependent patients, including, but not limited to, sequential lung isolation, prevention of hypothermia, and management of arrhythmias. Postoperative challenges may also include strategies to treat hemodynamic instability, managing the ventilator following lung derecruitment, and providing adequate pain control.We aimed to describe the anesthetic management of Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation patients undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation and the nature and incidence of perioperative complications.A retrospective chart review was performed of 14 children with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation undergoing phrenic nerve-diaphragm pacemaker implantation at a single academic pediatric hospital between 2009 and 2017. Demographic information, intraoperative management, and perioperative complications were analyzed from patient records.Twelve of 14 patients (86%) underwent an inhalational induction via tracheostomy. Lung isolation was achieved via fiberoptic guidance of a single lumen endotracheal tube sequentially into the right or left mainstem bronchi for 12 patients (86%). Double lumen endotracheal tubes were utilized in two patients (7%) and bronchial blockers in two patients (7%) for lung isolation. Anesthesia was maintained using a balanced technique of volatile agents (sevoflurane/isoflurane) and opioids (fentanyl). Bradyarrhythmias developed in six patients (43%) during surgery, 5 (36%) responded to anticholinergics and one patient (7%) required backup cardiac pacing using a previously implanted bipolar cardiac pacemaker. Intraoperative hypothermia (35.5°C) was present in five patients (36%) despite the use of warming devices. Hypercarbia (50 mm Hg) during lung isolation was present in eight patients (57%) and hemoglobin desaturation (90%) in four patients (29%). Postoperatively, oxygen desaturation was a common complication with nine patients (64%) requiring supplemental oxygen administration via mechanical ventilator or manual bag ventilation. Opioids via patient-controlled analgesia devices (12 patients, 86%) or intermittent injection (two patients, 14%) were administered to all patients for postoperative pain control. Phrenic nerve-diaphragm pacemaker placement was successful thoracoscopically in all patients with no perioperative mortality.The main anesthetic challenges in patients with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation include hemodynamic instability, the propensity to develop hypothermia, hypercarbia/hypoxemia, and the need to perform bilateral sequential lung isolation requisite to the thoracoscopic implantation technique. Most anesthetic agents can be used safely in these patients; however, adequate knowledge of the susceptibility to complications, coupled with adequate preparation and understanding of the innate disease characteristics, are necessary to treat anticipated complications.

We analysed data from the Paediatric Difficult Intubation Registry examining the use of direct laryngoscopy and GlideScope® videolaryngoscopy.Data collected by a multicentre, paediatric difficult intubation registry from 1295 patients were analysed. Rates of success and complications between direct laryngoscopy and GlideScope videolaryngoscopy were analysed.Initial (464/877 = 53% vs 33/828 = 4%, Z-test = 22.2, P 0.001) and eventual (720/877 = 82% vs. 174/828 = 21%, Z-test = 25.2, P 0.001) success rates for GlideScope were significantly higher than direct laryngoscopy. Children weighing10 kg had lower success rates with the GlideScope than the group as a whole. There were no differences in complication rates per attempt between direct laryngoscopy and GlideScope. The direct laryngoscopy group had more complications associated with the greater number of attempts needed to intubate. There were no increased risks of hypoxia or trauma with GlideScope use. Each additional attempt at intubation with either device resulted in a two-fold increase in complications (odds ratio: 2.0, 95% confidence interval: 1.5-2.5, P 0.001).During difficult tracheal intubation in children, direct laryngoscopy is an overly used technique with a low chance of success. GlideScope use was associated with a higher chance of success with no increased risk of complications. GlideScope use in children with difficult tracheal intubation has a lower success rate than in adults with difficult tracheal intubation. Children weighing less than 10 kilograms had lower success rates with either device. Attempts should be minimized with either device to decrease complications.

The design evolution of the pediatric supraglottic airway device has experienced a long and productive journey. We have a wealth of clinical studies to support progress and advancements in pediatric clinical practice. While all of the supraglottic airway devices have been used successfully in millions of children, it is important to be aware of design advantages and disadvantages of the different models of supraglottic airway devices. Current pediatric supraglottic airway devices may be improved in design to be more ideal. Industry-changing technological advancements are likely to occur in the near future, which may further improve clinical performance of these devices.

BACKGROUND Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial. The Pediatric Difficult Intubation (PeDI) Registry is an international multicenter registry that collects intubation data in difficult to intubate children. The registry captures the initial (at induction) and final ventilation technique (at intubation), the use of neuromuscular blocking drugs (NMBDs), airway reactivity during intubation, and complications. We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches. METHODS We queried the PeDI Registry for cases entered between September 2012 and February 2016, from 16 children's hospitals. We categorized the attending anesthesiologist's ventilation plan into 3 groups: spontaneous ventilation, controlled ventilation after administering an NMBD, and controlled ventilation without administering an NMBD. Generalized Estimating Equation (GEE) model, with a binomial family distribution and logit link, was used to determine the association between ventilation technique and the risk of complications, as well as to account for within-site clustering. Propensity score matching was further applied to balance pretreatment characteristics of ventilation groups. RESULTS Of 1289 anticipated difficult intubations, 507 (39%) were managed with spontaneous ventilation, 453 (35%) controlled ventilation with an NMBD, and 329 (26%) controlled ventilation without an NMBD. Complications occurred in 242 (18.8%; 95% confidence interval [CI], 16.6%-20.9%) patients. Of these, 218 (16.9%) were nonsevere, and 24 (1.9%) were severe. The spontaneous ventilation group had 114 (22.5%, standardized residual [Std.Res] = 4.29) nonsevere complications, which was higher than the controlled ventilation with an NMBD 60 (13.3%, Std.Res = -2.58), and controlled ventilation without an NMBD 44 (13.4%, Std.Res = -1.98), P < .001. Nearest neighbor matching with caliper width equal to 0.2 of the standard deviation (SD) of the logit of the propensity score also demonstrated that patients with spontaneous ventilation had greater odds of complications compared to controlled ventilation techniques: odds ratio (OR) = 2.07 (95% CI, 1.36-3.15; P = .001). CONCLUSIONS Spontaneous ventilation is associated with more nonsevere complications, such as hypoxemia and laryngospasm, than controlled ventilation techniques during intubation of children with difficult airways. Inadequate anesthetic depth may contribute to increased complications.

Structural and physiologic differences between pediatric and adult patients make management of the pediatric airway a challenge. Many initial airway device designs were modeled for adult patients and simply downsized for the pediatric population. This paper reviews the last decade's design improvements in video laryngoscopes and supraglottic airway devices (SGAs), as well as advances in noninvasive oxygenation/ventilation techniques for pediatric airway management.Topic areas reviewed include basic principles of common and newer devices for video laryngoscopy, supraglottic airway management, and alternate ventilation techniques. A literature search was conducted in PubMed using device-specific keywords and limited to neonatal, infant, and pediatric populations. Articles were reviewed for evidence deemed high yield by the authors. Device specifications were obtained from manufacturer correspondences. Features, comparisons, advantages, and disadvantages are provided for each device class. We give expert commentary regarding the current state of clinical application, research considerations, as well as a 5-year outlook on potential areas of device design and development.Video laryngoscopes and SGAs are safe and effective for use in children and improvements continue to be made for neonates and infants. The most significant area of new research is in the area of noninvasive airway devices for oxygenation and ventilation in difficult airways.

We conducted a randomised trial in 100 children in order to compare the clinical performance of the Ambu(®) AuraGain(™) and the LMA(®) Supreme(*) for airway maintenance during mechanical ventilation. The primary outcomes were initial and 10-min airway leak pressures. Ease, time and success rates for device and gastric tube insertion, fibreoptic grades of view, airway quality during anaesthetic maintenance, and complications were also assessed. There were no differences in the initial and ten min airway leak pressures between the Ambu AuraGain and LMA Supreme, median (IQR [range]) initial: 19 (16-22 [10-34]) vs 18 (14-24 [8-40]) cmH2 O, p = 0.4; and ten min: 22 (18-26 [11-40]) vs 20 (16-26 [12-40]) cmH2 O, p = 0.08, respectively. Ease, time and success rates for device placement, gastric tube insertion and complications were also not significantly different. Children receiving the LMA Supreme required more airway manouevers (7 vs 1 patient, p = 0.06) to maintain a patent airway. Our results suggest that the Ambu AuraGain may be a useful alternative to the LMA Supreme, as demonstrated by comparable overall clinical performance in children.

Background There is a paucity of data regarding risk stratification of pediatric patients presenting for low-risk skin and soft tissue surgery. Aims We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30-day readmission in a cohort of children undergoing low-risk skin and soft tissue surgery. Methods The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two-year period. The primary outcome was a 30-day postoperative complication composite. The secondary outcome was unplanned 30-day readmission. Results The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound-related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30-day readmission. Conclusion Pediatric patients with American Society of Anesthesiologists classification ≥3 and nutritional deficiency undergoing low-risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30-day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications.

Summary Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

To present a case of unintentional tracheal extubation in a prone positioned patient with a known difficult airway.This case report describes the unintended tracheal extubation of an achondroplastic dwarf with kyphosis undergoing spinal fusion and instrumentation. The patient had a history of obstructive sleep apnea and a difficult airway requiring fibreoptic-guided tracheal intubation through an air-Q™ supraglottic airway device. Abrupt head movement during a wake-up test to evaluate lost motor-evoked potential signals resulted in dislodgement of the tracheal tube. Airway obstruction was evidenced by rapid oxygen desaturation and the absence of end-tidal capnography waveforms despite apparent chest excursions. An air-Q was used for successfully rescuing the airway and quickly re-establishing oxygenation and ventilation, which eliminated the need for emergent supine positioning for airway management. The air-Q was then used as a conduit for fibreoptic-guided tracheal intubation while the patient remained in the prone position.This case highlights some of the safety advantages of supraglottic airway devices for airway rescue and subsequent tracheal intubation even with the patient in the prone position. The use of an air-Q may have the advantages of not requiring an intubation introducer technique and allowing for direct tracheal intubation with an appropriately sized cuffed tracheal tube.

Background Supraglottic airways (SGAs) have an established role in airway management of difficult airways in both adults and children. However, there are limited data regarding the use of SGAs for primary airway management in children. The aim of this study is to assess the success rates and adverse events related to the use of SGAs for primary airway management during anaesthesia in children with difficult airways. Methods A retrospective analysis of SGA use for primary airway management in the difficult airway population in a single centre over a 4-yr period was performed. Difficult airway was defined as either a history of difficult direct laryngoscopy (a documented Cormack and Lehane Grade 3 or greater and the need for an alternate device to direct laryngoscopy for successful tracheal intubation), a history of difficult mask ventilation, or both. The difficult airway condition, patient characteristic data, type and length of procedure, type and size of SGA placed, number of attempts for successful device placement, success/failure associated with the device during anaesthetic maintenance, and complications were recorded. Results A total of 77 272 children received general anaesthesia in a free-standing paediatric institution. Four hundred and fifty-nine patients were reported to have a difficult airway. Of those, 109 received general anaesthesia and an SGA for primary management, meeting the inclusion criteria for this study during a 4-yr period. An SGA was successfully used in 96% of these patients. In four patients, an alternative airway was needed. Conclusions SGAs can be effectively utilized for airway maintenance in the paediatric difficult airway population.

To date, the independent predictors and outcomes of unplanned postoperative intubation (UPI) in pediatric patients after noncardiac surgery are yet to be characterized. The authors aimed to identify the incidence and predictors of this event and evaluated the effect of this event on postoperative mortality.Data of 87,920 patients from the American College of Surgeons National Surgical Quality Improvement Program Pediatric database were analyzed and assigned to derivation (n = 58,614; 66.7%) or validation (n = 29,306; 33.3%) cohorts. The derivation cohort was analyzed for the incidence and independent predictors of early UPI. The final multivariable logistic regression model was validated using the validation cohort.Early UPI occurred with an incidence of 0.2% in both cohorts. Among the 540 patients who experienced a UPI, 178 (33.0%) were intubated within the first 72 h after surgery. The final logistic regression model indicated operation time, severe cardiac risk factors, American Society of Anesthesiologists physical status classification more than or equal to 2, tumor involving the central nervous system, developmental delay/impaired cognitive function, past or current malignancy, and neonate status as independent predictors of early UPI. Having an early UPI was associated with an increased risk of unadjusted, all-cause 30-day mortality, demonstrating an odds ratio of 11.4 (95% CI, 5.8 to 22.4).Pediatric patients who experienced an early UPI after noncardiac surgery had an increased likelihood of unadjusted 30-day mortality by more than 11-fold. Identification of high-risk patients can allow for targeted intervention and potential prevention of such outcomes.

Summary Objectives To assess the clinical performance of the Ambu Aura-i (Aura-i) in children. Aim To compare the Aura-i with the air-Q intubating laryngeal airway (air-Q) for the purposes of fiberoptic-guided tracheal intubation. Background The Aura-i is a new supraglottic airway designed for tracheal intubation. Materials/Methods One hundred twenty children, ages 1 month to 6 years, were randomized to receive either the Aura-i or air-Q, and divided into three equal subgroups (Group 1, 2, 3) based on weight. The time for successful tracheal intubation was primarily assessed. The ease, time, and number of attempts for successful device insertion, leak pressures, fiberoptic grade of laryngeal view, number of attempts time for removal of the device after tracheal intubation, and complications were secondarily assessed. Results Device placement, tracheal intubation, and removal after tracheal intubation were successful in all patients. There were no differences in the time to successful tracheal intubation through the Aura-i (32.9 ± 13.3 s), and the air-Q (33.9 ± 13 s; P = 0.68), or fiberoptic grade of view between devices. There was not a statistically significant correlation between the time to intubation and the fiberoptic grade of laryngeal view in any of the groups. There were no statistically significant differences in the overall leak pressures, air-Q (18.3 ± 6.1 cm H2O) vs Aura-i (16 ± 5.1 cm H2O; P = 0.05). In Group 1 (5–10 kg), leak pressures were higher with the air-Q (23.4 ± 7.2 cm H2O) than the Aura-i (16.1 ± 5.2 cm H2O; P = 0.001). There were no statistically significant differences in the time for removal between the two devices (P = 0.11). However, with the size 1.5 Aura-i, the pilot balloon of the tracheal tube was removed in order to facilitate the removal of the device after tracheal intubation. Conclusions Both devices served as effective conduits for fiberoptic-guided tracheal intubation. The limitation of the narrower proximal airway tube of the size 1.5 Aura-i should be considered if cuffed tracheal tubes are to be utilized.

BACKGROUND: The air-Q™ Intubating Laryngeal Airway (ILA) (Cookgas LLC, Mercury Medical, Clearwater, FL) is a supraglottic airway device available in pediatric sizes, with design features to facilitate passage of cuffed tracheal tubes when used to guide tracheal intubation. We designed this prospective observational study of the ILA to assess the ease of its placement in paralyzed pediatric patients, determine its position and alignment to the larynx using a fiberoptic bronchoscope, gauge its efficacy as a conduit for fiberoptic intubation with cuffed tracheal tubes, and evaluate the ability to remove the ILA without dislodgement of the tracheal tube after successful tracheal intubation. METHODS: One hundred healthy children, aged 6 months to 8 years, ASA physical status I to II, and scheduled for elective surgery requiring general endotracheal anesthesia were enrolled in this prospective study. Based on the manufacturer’s guidelines, each patient received either a size 1.5 or 2.0 ILA according to their weight. The number of attempts for successful insertion, leak pressures, fiberoptic grade of view, number of attempts and time for tracheal intubation, time for ILA removal, and complications were recorded. RESULTS: ILA placement, fiberoptic tracheal intubation, and ILA removal were successful in all patients. The size 1.5 ILA cohort had significantly higher rates of epiglottic downfolding compared with the size 2.0 ILA cohort (P 0.001), despite adequate ventilation variables. When comparing fiberoptic grade of view to weight, a moderate negative correlation was found (r 0.41, P 0.001), indicating that larger patients tended to have better fiberoptic grades of view. The size 1.5 ILA cohort had a significantly longer time to intubation (P 0.04) compared with the size 2.0 ILA cohort. However, this difference may not be clinically significant because there was a large overlap of confidence bounds in the average times of the size 1.5 ILA (27.0 13.0 seconds) and size 2.0 ILA cohorts (22.7 6.9 seconds). When comparing weight to time to tracheal intubation, a weak correlation that was not statistically significant was found (r 0.17, P 0.09), showing that time to intubation did not differ significantly according to weight, despite higher fiberoptic grades in smaller patients. CONCLUSIONS: The ILA was easy to place and provided an effective conduit for tracheal intubation with cuffed tracheal tubes in children with normal airways. Additionally, removal of the ILA after successful intubation could be achieved quickly and without dislodgement of the tracheal tube. Because of the higher incidence of epiglottic downfolding in smaller patients, the use of fiberoptic bronchoscopy is recommended to assist with tracheal intubation through this device. (Anesth Analg 2011;112:176–82)

There are innumerable tools and devices available to facilitate airway management and life-saving gas exchange of the patient’s lungs. Over the years, various designs and generations of supraglottic airway devices have proven to be effective in accomplishing this function. Their application has grown beyond the original purpose of controlling the normal pediatric airway without tracheal intubation, and has been incorporated in the difficult airway management algorithms of anesthesia societies around the world based on clear evidence of efficacy. Older supraglottic airway devices since the 1980’s have been validated in multiple clinical trials to be safe and effective in the pediatric population, however there is also sufficient evidence that the newer designs have features that help overcome some limitations. These newer designs and features are effective in managing both the normal and difficult pediatric airway, and will be discussed in this comprehensive review.

SummaryBackground Tracheal extubation in children with difficult airways may be associated with an increased risk of perioperative adverse events. Aims The aim of this study was to describe the exubation techniques used/ success rates/ adverse events related to tracheal extubation practices in children with difficult airways. Methods A retrospective analysis of tracheal extubation practices in the difficult airway population over a 78-month period was performed. Difficult airway was defined as a Cormack and Lehane Grade 3 view or greater, and/or tracheal intubation requiring ≥3 attempts, and/or the need for an alternate device to direct laryngoscopy for successful tracheal intubation, and/or difficult mask ventilation. Reasons for difficult airway, demographic/surgical data, technique(s) for tracheal extubation, success/failure of tracheal extubation, and adverse events were recorded. A failed tracheal extubation was defined as any adverse event related to the airway occurring within 6 h of extubation requiring reintubation. Results A total of 519 patients were reported to have a difficult airway during this study period in a tertiary care pediatric center. Of these, 137 patients (26%) met inclusion criteria. Tracheal extubation was successfully performed in 130 patients (95%). The majority of tracheal exubations were performed without the use of additional airway adjuncts straight onto anesthesia face mask (121/137; 88%). Extubation failure occurred in seven cases (5%). Among the failed extubations, 6/7 children (85%) had evidence of severe upper airway obstruction and were

Summary 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 children's 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.

Supraglottic airways are commonly used as conduits for fibreoptic bronchoscopy (FOB)-guided intubation in pediatric patients. We hypothesized that anesthesiology trainees with limited prior experience with FOB-guided intubation through a supraglottic airway in children would intubate the trachea faster through the air-Q™ supraglottic airway than through the i-gel™. Ninety-six children aged one month to six years were randomized to receive either the i-gel or air-Q for FOB-guided tracheal intubation by anesthesiology trainees. Time for successful tracheal intubation was the primary endpoint. Secondary endpoints included: time for device insertion, number of attempts for successful device insertion, airway leak pressures, FOB grade of laryngeal view, total number of attempts for tracheal intubation, time for removal of the device after tracheal intubation, and associated complications. The median (interquartile range [IQR]) times to successful tracheal intubation for the air-Q (62.5 [47.9-77] sec) and the i-gel (55.9 [48.5-81.8] sec) were not significantly different (median difference 6.6 sec; 95% confidence interval [CI] -13.3 to 8.7; P = 0.53). The median (IQR) time to insertion for the air-Q (16.7 [14.4-20.0] sec) was shorter than for the i-gel (19.6 [16.7-23.0] sec) (median difference 2.9 sec; 95% CI 0.8 to 4.7; P = 0.005). There were no differences between devices with respect to airway leak pressures, success rates, and time to removal. Compared with the air-Q, the i-gel was associated with more problems during device removal after tracheal intubation, including breakage of the tracheal tube pilot balloon (n = 0 vs n = 13, respectively; P

Summary Background The cuff pressure for optimal airway sealing with first-generation laryngeal mask airway has been shown to be 40 cm H2O in children. Currently, there are no data regarding the ideal intracuff pressure for the laryngeal mask airway Supreme (Supreme) in children. Objectives To compare the clinical performance of the laryngeal mask airway supreme with the laryngeal mask airway unique in infants and children. Materials and methods One hundred eighty children were assigned to receive either a Supreme or a laryngeal mask airway-U. We hypothesized higher airway leak pressure with the Supreme at both 40 cm H2O and 60 cm H2O, when compared with the laryngeal mask airway-U. Ease and time of insertion, insertion attempts, fiber optic examination, quality of airway, efficacy of mechanical ventilation, success of gastric tube placement (Supreme), incidence of gastric insufflation, and complications were also assessed. Results Airway leak pressure at an intracuff pressure of 60 cm H2O for the Supreme was 17.4 (5.2) vs laryngeal mask airway-U at 18.4 (6.6) cm H2O and did not differ when compared to an intracuff pressure of 40 cm H2O for both devices; Supreme at 17.2 (5) vs laryngeal mask airway-U at 17.7 (6) cm H2O. The laryngeal mask airway-U was associated with higher first-attempt success rates. The Supreme was associated with less gastric insufflation than the laryngeal mask airway-U. Conclusions Intracuff pressures of 40 cm H2O may be sufficient for the Supreme in children, and there may be no added benefit of an intracuff pressure of 60 cm H2O, as leak pressures were similar. The Supreme may be preferred over the laryngeal mask airway-U for its lower rates of gastric insufflation and provision for gastric access when mechanical ventilation is utilized.

Regional anesthetic techniques for perioperative analgesia in children are being increasingly utilized with the reported advantages of providing superior analgesia, decreasing opioid consumption, and reducing opioid-related adverse effects. The following article reviews the available literature regarding core and trunk blocks in infants and children; specifically, transversus abdominis plane, ilioinguinal/iliohypogastric nerve, rectus sheath, lumbar plexus, and paravertebral and intercostal nerve blockade. The common indications and potential complications and adverse effects for each block are presented. Additionally, the anatomy and techniques needed for their performance are reviewed. Finally, a summary of the relevant literature in relation to each peripheral nerve block technique is included.

Objective To evaluate the intubating laryngeal airway (ILA) in providing safe endotracheal intubation in pediatric patients with difficult airway; to describe a method for using flexible fiberoptic bronchoscopy with the ILA for evaluating the pediatric airway. Methods Case series with chart review of the medical records of patients who had the ILA and fiberoptic intubation used to secure the airway at a tertiary pediatric hospital from January 2009 to January 2011. We documented the circumstances necessitating airway management, ILA success, airway evaluation findings, and medical conditions contributing to difficult airway. Results Fifty patients met criteria for review. The median age was 59.8 months (0.3–244.1), and the median weight was 19.0 kg (2.6–86). Four cases (8%) were unanticipated difficult airways and 46 (92%) were anticipated difficult airways. Nine (18%) of the 50 procedures were performed emergently. Comorbid conditions included craniofacial syndromes (n = 36), cervical spine instability/immobility (n = 9), and airway hemorrhage (n = 3). 48 (96%) patients were fiberoptically intubated on first attempt through the ILA. In 2 patients, fiberoptic intubation required a second attempt. The overall success rate using the ILA and fiberoptic intubation to secure the airway was 100%. Conclusion ILA and fiberoptic-guided tracheal intubation is a safe and effective method for securing the airway in pediatric patients with difficult airway and can be a useful alternative to direct laryngoscopy when laryngeal exposure is suboptimal.

To assess the clinical performance of the laryngeal mask airway-Supreme in children.The purpose of this prospective audit was to evaluate the feasibility of the laryngeal mask airway-Supreme in clinical practice and generate data for future comparison trials.The laryngeal mask airway-Supreme is a new second-generation supraglottic airway that was recently released in limited pediatric sizes (sizes 1, 2).One hundred children, ASA I-III, newborn to 16 years of age, and undergoing various procedures requiring a size 1, 2, or 3 laryngeal mask airway-Supreme were studied. Assessments included insertion success rates, airway leak pressures, success of gastric tube insertion, quality of airway, and perioperative complications.The first-time insertion success rate was 97%, with an overall insertion success rate of 100%. The mean initial airway leak pressure for all patients was 22.3 ± 6.6 cm H(2) O. Gastric tube placement was possible in 98% of patients. Complications were noted in six patients: coughing or laryngospasm (n = 3), sore throat (n = 1), and dysphonia (n = 2).The laryngeal mask airway-Supreme was inserted with a high degree of success on the first attempt by clinicians with limited prior experience with the device. It was effectively used for a variety of procedures in children undergoing spontaneous and mechanical ventilation with minimal complications. The leak pressures demonstrated in this study, along with access for gastric decompression, suggest that the laryngeal mask airway-Supreme may be an effective device for positive pressure ventilation in children.

To the Editor, When encountering patients with difficult airways in pediatric anesthesia, clinicians have the option of using a supraglottic airway device as a conduit for tracheal intubation. The Laryngeal Mask Airway (LMA) Classic (LMA North America; San Diego, CA, USA) is the conduit used most commonly for tracheal intubation in the pediatric population. However, numerous challenges arise when the LMA is used to facilitate intubation with an endotracheal tube (ETT), especially during removal of the LMA following successful intubation. In particular, the airway tube of the LMA can be as long as the ETT, making it difficult to maintain control of the ETT while removing the LMA. Several techniques that decrease the likelihood of accidental extubation of the ETT during removal of the LMA have been devised and reported in the literature. These techniques include the use of a long ETT, a double ETT assembly, shortening or splitting the shaft of the LMA, or leaving the LMA in place for the duration of surgery. These techniques are all effective yet imperfect solutions to a procedure commonly encountered in a patient with a difficult airway. The air-Q intubating laryngeal airway (ILA) (Cookgas LLC; St. Louis, MO, USA) is a newer supraglottic airway device that holds several advantages over the LMA when used to facilitate tracheal intubation in the pediatric population. Specifically, the airway tube of the ILA is shorter and wider than the LMA, which allows for greater control of the ETT and unhindered passage of the pilot balloon during removal of the ILA. At our institution, we have intubated the tracheas of hundreds of patients successfully by using the ILA as a conduit for tracheal intubation. It has been noted that the shorter airway tube length greatly facilitates distal control of the ETT and subsequent removal of the ILA after intubation. Unlike the LMA, the ILA has a custom removal stylet that can be used to stabilize the ETT during removal of the ILA device. However, if the manufacturer’s removal stylet is not available or if the clinician is not comfortable with its use, we propose the use of an airway exchange catheter (AEC) (Cook Medical, Bloomington, IN, USA) to facilitate removal of the ILA (Figure). Use of an AEC during removal of the ILA offers advantages to the clinician who otherwise might be hesitant to remove the ILA after tracheal intubation. First, placement of the AEC maintains the ability to supply supplemental oxygen into the trachea and diminishes the possibility of oxygen desaturation. Second, the AEC provides a means for guided reintubation if the ETT is dislodged inadvertently during removal of the ILA device. Generally, the smaller-sized ILAs (1.0 and 1.5) are short enough to facilitate gaining both proximal and distal control of the ETT during removal of the ILA. If an AEC is used, the clinician could cede control of the ETT once its proximal end is flush with the ILA and still retain proximal control of the AEC to ensure it remains in the trachea. The clinician can then remove the ILA until distal control of the ETT is possible, even if outside the patient’s mouth, and then confirm tracheal depth and reintubate over the AEC if necessary. Another potential technique that has been described for tracheal intubation through the LMA is to leave the fibreoptic bronchoscope within the trachea while removing the LMA, then to advance the ETT down the bronchoscope into the trachea. This method is beneficial, as no additional N. Jagannathan, MD (&) R. J. Kozlowski, BS Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA e-mail: simjag2000@yahoo.com

Summary Background: Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single-shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double-blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication. Methods: Fifty children ages 1–6 years scheduled for unilateral inguinal hernia repair, hydrocelectomy, orchidopexy, or orchiectomy were prospectively randomized into one of two groups: Group S that received an US-guided ilioinguinal nerve block with 0.1 ml·kg−1 of preservative-free normal saline and Group B that received an US-guided nerve block with 0.1 ml·kg−1 of 0.25% bupivacaine with 1 : 200 000 epinephrine at the conclusion of the surgery. After induction of anesthesia but prior to surgical incision, all patients received caudal anesthesia with 0.7 ml·kg−1 of 0.125% bupivacaine with 1 : 200 000 epinephrine. Patients were observed by a blinded observer for (i) pain scores using the Children and Infants Postoperative Pain Scale, (ii) need for rescue medication in the PACU, (iii) need for oral pain medications given by the parents at home. Results: Forty-eight patients, consisting of 46 males and two females, with a mean age of 3.98 (sd ± 1.88) were enrolled in the study. Two patients were excluded from the study because of study protocol violation and/or alteration in surgical procedure. The average pain scores reported for the entire duration spent in the recovery room for the caudal and caudal/ilioinguinal block groups were 1.92 (sd ± 1.59) and 1.18 (sd ± 1.31), respectively. The average pain score difference was 0.72 (sd ± 0.58) and was statistically significant (P

To the Editor, Use of a supraglottic airway device as a conduit for tracheal intubation has changed the practice of pediatric anesthesia, especially in the management of patients with difficult airways. For many years, the Laryngeal Mask Airway (LMA) Classic (LMA North America, San Diego, CA, USA) was the device most commonly used for this purpose in pediatric anesthesia. However, there are some limitations when the LMA is used to facilitate fibreoptic intubation with a cuffed endotracheal tube (ETT), particularly during subsequent removal of the LMA. The Intubating Laryngeal Airway (ILA) (Cookgas LLC, St. Louis, MO, USA) is a new supraglottic airway device that is comparable to the LMA in terms of its ease of insertion and functionality, but with a conduit sufficient in size to accommodate a larger cuffed ETT. There are no intubating LMAs currently available for patients weighing \30 kg, and the ILA, which is available in pediatric sizes, can be used to facilitate tracheal intubation in these patients. A Stabilizer Rod is used to facilitate removal of the LMA after successful tracheal intubation. Like the LMA, the ILA has a Removal Stylet available to steady the ETT during removal of the ILA device. The ILA lumen is of sufficient size to accommodate the Stylet and the pilot balloon of the ETT during withdrawal of the ILA (Figure 1A-C). In clinical practice, however, an uncuffed ETT is often used in lieu of the manufacturer’s removal stylet when removing the LMA or ILA after using either as a conduit for tracheal intubation in children (Figure 1D-F). The ILA lumen cannot accommodate both the pilot balloon and the ETT during ILA withdrawal (Figure 1F), and entrapment of the pilot balloon within the airway tube may lead to cuff line rupture if the ILA is withdrawn further in that situation. The disadvantages of using two tracheal tubes include the potential for cuff line rupture or inadvertent ETT dislodgement upon removal of the ILA. To avoid either situation, control of the distal cuffed ETT must be maintained while the proximal ETT is first removed from the ILA (Figure 1E). After that, the cuff line and the pilot balloon can pass through the ILA airway tube unhindered. This is of particular importance in the management of the difficult airway, where the initial securing of the airway may have been difficult and where re-intubation may be accompanied by untoward problems. It is convenient to use a second ETT as a stabilizing rod for removal of the ILA after successful tracheal intubation, because an ETT is readily available in the operating room and is used commonly when removing the LMA-Classic after tracheal intubation in pediatric patients. As the ILA and tracheal intubation with cuffed ETTs become more common in pediatric anesthesia, awareness of the limitations of using an ETT as a stabilizing rod to assist in removal of the ILA is clinically important. In our clinical experience of more than 100 ILA-guided tracheal intubations, we have used a tracheal tube primarily as a stabilizing rod when removing the ILA. However, we have encountered difficulty when removing the ILA with the use N. Jagannathan, MD (&) M. F. Kho, MS Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA e-mail: simjag2000@yahoo.com