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BackgroundDifficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation.MethodsWe queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed.ResultsThe incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening.ConclusionsCertain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

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: One lung ventilation (OLV) in small children can be achieved using an Arndt endobronchial blocker (AEBB), but it presents challenges. OLV during thoracic procedures provides better surgical conditions and postoperative outcomes. Aim: To report a novel technique to improve placement and repositioning of an extraluminal AEBB for OLV. Material and Methods: We describe how an angled wire is successfully used for extraluminal AEBB placement in pediatric thoracic procedures. Discussion: Since 2017, we have successfully used this technic in over 50 infants and toddlers and overcome challenges of the classic OLV in this age group. Conclusions: The described technique allows for fast, safe, and reliable OLV while maintaining the ability to reposition the AEBB. [ABSTRACT FROM AUTHOR]

Background: Spinal muscular atrophy is a group of autosomal recessive inherited neurological disorders secondary to a genetic mutation that leads to progressive muscle weakness and atrophy. Recently approved by the Food and Drug Administration, Nusinersen is the first treatment specifically for spinal muscular atrophy. This drug must be administered intrathecally, as it does not cross the blood‐brain barrier. Aims: Retrospective review of the individualized perioperative care of spinal muscular atrophy type I and II patients for intrathecal Nusinersen injection. Methods: After approval from the Institutional Review Board and obtaining informed written consent from parents, we reviewed the anesthetic charts of nine patients who underwent 58 Nusinersen injections over a 23‐month period from February 2017 to December 2018. An individualized anesthetic plan was formulated based on the patient's disease severity, anxiety level, and comfort of parents as well as the provider performing the procedure. Patients underwent intrathecal Nusinersen injection under fluoroscopic guidance, with either general anesthesia, monitored anesthesia care with medications or monitored anesthesia care without medications. Patients recovered in the postanesthesia care unit for a minimum of 1 hour after injection, irrespective of the anesthetic method utilized. Analysis included patient demographics, anesthesia type relative to spinal muscular atrophy type I vs. II, and postanesthesia recovery. Results: Nine patients with spinal muscular atrophy types I and II underwent 58 encounters. Five spinal muscular atrophy type I patients underwent 31 encounters, general anesthesia (9), monitored anesthesia care with medications (2), and monitored anesthesia care without medications (20). Four spinal muscular atrophy type II patients underwent 27 encounters, general anesthesia (22), monitored anesthesia care with medications (2), and monitored anesthesia care without medications (3). There were no perioperative complications. Conclusion: The anesthetic plan for Nusinersen injections must be individualized to the patient's specific needs and clinical manifestations of the disease. When carefully tailored to each patient, anesthetic care is safe and successful. [ABSTRACT FROM AUTHOR]

Thank you Dr. Eklund for your informative and interesting research report about the epidural catheter placement in children with the baclofen pumps published on November 01, 2020.1 The study evaluated 16 patients for adverse events related to epidural catheter placement for orthopedic surgeries in children with intrathecal baclofen pump. The epidural was inserted at T12-L1, which was the best-palpated space; loss of resistance with saline was at a depth of 2.5 cm. The StimuLong Sono Tsui II epidural catheter (Pajunk[ SP ® sp ] GmbH).2 was then placed with continuous stimulation. The tip of this epidural catheter being radio-opaque an X-ray was obtained to confirm the level of catheter tip for intraoperative and postoperative use. [Extracted from the article]

Background: Children with obstructive sleep apnea (OSA) have a higher rate of adverse post-extubation respiratory events, such as laryngospasm, upper airway obstruction, apnea, desaturation and/or need for re-intubation. They are overly sensitive to sedatives and narcotics. Although the etiology of OSA is primarily obstruction (mechanical or neuromuscular), a central element may contribute to OSA. Caffeine citrate has been shown to be effective in treating apnea of prematurity. This study evaluated whether the administration of caffeine benzoate to children with OSA decreases the number of children who experience adverse post-extubation respiratory events., Methods: In a randomized, double-blind and placebo-controlled study, children with OSA scheduled for adenotonsillectomy (T&A) received either caffeine benzoate, 20 mg/kg IV, (caffeine group, n = 36) or saline (placebo group, n = 36). The primary outcome evaluated the number of children who developed adverse post-extubation respiratory events, and the secondary outcome was the incidence of those events., Results: The results demonstrated the two groups differed in the number of children who developed adverse post-extubation respiratory events (p = 0.032). The overall incidence of adverse postoperative respiratory events was less in the caffeine group than the placebo group (p = 0.0196)., Conclusion: In children with OSA scheduled for T&A, administration of caffeine benzoate, 20 mg/kg IV, decreased the number of children who developed adverse post-extubation respiratory events and decreased the overall incidence of adverse post-extubation respiratory events. PACU duration, hospital discharge time and postoperative delirium did not differ between groups.