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Background and Objectives: Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life‐threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front‐of‐neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front‐of‐neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front‐of‐neck access in children. Methods: A comprehensive literature was performed the use of emergency front‐of‐neck access (eFONA) in infants and children. Results: Eighty‐six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported. Conclusion: Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure. [ABSTRACT FROM AUTHOR]

Introduction. Pediatric airway management poses unique challenges due to anatomical differences from adults, rendering children more susceptible to airway complications. Historically, uncuffed endotracheal tubes (ETTs) were preferred in pediatric intubation to minimize risks, but microcuffed (low volume, low pressure) ETTs offer advantages including improved seal and better ventilation efficiency. This study aims to compare the ease of intubation and post-operative airway complications between microcuffed and uncuffed ETTs. Aim. To assess the ease of intubation and post-extubation complications of the airway due to the use of microcuffed endotracheal tubes and uncuffed endotracheal tubes. Methodology. An observational study was conducted on pediatric patients aged 0-10 years undergoing elective surgeries under general anesthesia. Convenience sampling was used to select 54 participants. Patients were divided into two groups: uncuffed endotracheal tube (UG) and cuffed endotracheal tube (CG). Data on intubation attempts and post-operative complications were collected. Results. Baseline characteristics including age, gender, weight, and ASA grade were comparable between groups. Single-attempt intubation success was higher in the uncuffed group (55.6%) compared to the cuffed group (40.7%). Post-operative complications such as respiratory distress, stridor, hypoxemia, and restlessness were more prevalent in the uncuffed group but not statistically significant. Conclusion. This observational study suggests fewer postoperative complications with cuffed endotracheal tube insertion in pediatric patients. However, more research is needed to confirm these findings and explore the efficacy of microcuffed tubes in pediatric anesthesia.

Introduction. Pediatric airway management poses unique challenges due to anatomical differences from adults, rendering children more susceptible to airway complications. Historically, uncuffed endotracheal tubes (ETTs) were preferred in pediatric intubation to minimize risks, but microcuffed (low volume, low pressure) ETTs offer advantages including improved seal and better ventilation efficiency. This study aims to compare the ease of intubation and post-operative airway complications between microcuffed and uncuffed ETTs. Aim. To assess the ease of intubation and post-extubation complications of the airway due to the use of microcuffed endotracheal tubes and uncuffed endotracheal tubes. Methodology. An observational study was conducted on pediatric patients aged 0-10 years undergoing elective surgeries under general anesthesia. Convenience sampling was used to select 54 participants. Patients were divided into two groups: uncuffed endotracheal tube (UG) and cuffed endotracheal tube (CG). Data on intubation attempts and post-operative complications were collected. Results. Baseline characteristics including age, gender, weight, and ASA grade were comparable between groups. Single-attempt intubation success was higher in the uncuffed group (55.6%) compared to the cuffed group (40.7%). Post-operative complications such as respiratory distress, stridor, hypoxemia, and restlessness were more prevalent in the uncuffed group but not statistically significant. Conclusion. This observational study suggests fewer postoperative complications with cuffed endotracheal tube insertion in pediatric patients. However, more research is needed to confirm these findings and explore the efficacy of microcuffed tubes in pediatric anesthesia. [ABSTRACT FROM AUTHOR]

This study primarily aims to determine the frequency of life-threatening conditions among pediatric patients served by the DRF, a German helicopter emergency service (HEMS) provider. It also seeks to explore the necessity of invasive procedures in this population, discussing the implications for HEMS crew training and service configuration based on current literature. We analyzed the mission registry from 31 DRF helicopter bases in Germany, focusing on 7954 children aged 10 or younger over a 5-year period (2014–2018). Out of 7954 identified children (6.2% of all primary missions), 2081 (26.2%) had critical conditions. Endotracheal intubation was needed in 6.5% of cases, while alternative airway management methods were rare (n = 14). Half of the children required intravenous access, and 3.6% needed intraosseous access. Thoracostomy thoracentesis and sonography were only performed in isolated cases. Conclusions: Critically ill or injured children are infrequent in German HEMS operations. Our findings suggest that the likelihood of HEMS teams encountering such cases is remarkably low. Besides endotracheal intubation, life-saving invasive procedures are seldom necessary. Consequently, we conclude that on-the-job training and mission experience alone are insufficient for acquiring and maintaining the competencies needed to care for critically ill or injured children. What is Known: • Pediatric emergencies are relatively rare in the prehospital setting, but their incidence is higher in helicopter emergency medical services (HEMS) compared to ground-based emergency services. What is New: • On average, HEMS doctors in Germany encounter a critically ill or injured child approximately every 1.5 years in their practice, establish an IV or IO access in infants or toddlers every 2 years, and intubate an infant every 46 years. • This low frequency highlights the insufficiency of on-the-job training alone to develop and maintain pediatric skills among HEMS crews. Specific interdisciplinary training for HEMS crews is needed to ensure effective care for critically unwell pediatric patients. [ABSTRACT FROM AUTHOR]

Parapharyngeal tumors often distort the airway anatomy leading to obstruction and hinderance for intubation thus posing a challenge for the anesthetist at securing airway with least damage to the nearby structures. We present our experience through a series of 5 such cases in children managed successfully using video laryngoscope. Working in places where availability of advanced airway equipment such as pediatric size fiberoptic is unavailable, a video laryngoscope can help to appropriately assess the airway and prevent disastrous outcomes.

Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials. [ABSTRACT FROM AUTHOR]

Abstract Background Adams-Oliver syndrome is characterized by the combination of congenital scalp defects and terminal transverse limb defects. In some instances, cardiovascular malformations and orofacial malformations have been observed. Little is written with regards to the anesthetic management and airway concerns of patients with Adams-Oliver syndrome. Case presentation A five-year-old female with Adams-Oliver syndrome presented for repeat lower extremity surgery. Airway exam was significant for dysmorphic features, such as hypertelorism, deviated jaw, and retrognathia. Video laryngoscope was utilized for intubation due to the patients retrognathic jaw, cranial deformities, and facial dysmorphism. A vein finder with ultrasound guidance was needed to place the peripheral intravenous line due to her history of difficult intravenous access. The patient was successfully intubated with slight cricoid pressure applied to direct the endotracheal tube smoothly. Surgery and recovery were both unremarkable. Conclusions Due to varying presentations of Adams-Oliver syndrome, anesthetic and airway management considerations should be carefully assessed prior to surgery. Anesthesiologists must take into consideration possible orofacial abnormalities that may make intubation difficult. Amniotic band syndrome and other limb defects could potentially impact intravenous access as well.

Background: Choosing the correct Endotracheal tube (ETT) size is important in paediatric patients because an inappropriately large and small sized tube has its own disadvantages and chances of re-intubation with different size tube is high. The currently available modalities do not reflect the actual tracheal diameter for selection of endotracheal tube. Ultrasonography (USG) guided evaluation of transverse diameter at subglottic region may be helpful to estimate the proper size of ETT. We tested the hypothesis that Ultrasound guided subglottic diameter better predicts optimal ETT size than existing methods. Aims: To predict the appropriate size of ETT in pediatric patients to avoid multiple attempts of intubation and airway edema using simple noninvasive USG-guided methods. Settings and Design: Design: Prospective study. Settings: Tertiary care hospital. Materials and Methods: Institutional ethical committee clearance no. BMCRI/PS/138/2020-21 was taken. Laryngoscopy and endotracheal intubation were done in 27 pediatric patients of age 2-15 years using a predetermined-sized ETT, estimated by ultrasonography. ETT size was considered optimal when the cuff leak test was negative. If there was resistance to ETT passage into the trachea, the tube was exchanged with one that was 0.5 mm smaller. If the cuff leak test was positive, then the ETT was exchanged for one with the 0.5-mm larger tube. The comparison was done between the size of ETT calculated by USG-guided subglottic diameter, age, height-related formulas, and clinical methods to look for accuracy of prediction for proper ETT size after cuff leak test. Statistical Analysis: The data collected were entered into Microsoft Excel and analyzed using SPSS version 22. IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Appropriate parametric and nonparametric tests were applied wherever necessary. Categorical data: Represented in the form of frequencies and proportions. Continuous data: Represented as mean and standard deviation. Paired sample test: Test to identify the mean difference between two quantitative variables. Kappa statistics: To measure the level of agreement. Results: A total of 27 children of age between 2 and 15 years were selected, out of which 15 were male and 12 were female. The accuracy of predicting appropriate ETT size is greater in ultrasound-guided subglottic diameter when compared to conventional clinical assessment and age- and height-related formula and almost the same accuracy as the clinical method. Conclusion: Ultrasound-guided subglottic diameter is an easy, effective, and noninvasive way of predicting accurate ETT size in the pediatric population. [ABSTRACT FROM AUTHOR]

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow. NAEMSP recommends: Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles. EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies. EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children. Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting. Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation. If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention. Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention. [ABSTRACT FROM AUTHOR]

Although pediatric airway and respiratory emergencies represent high-acuity situations, the ability of EMS clinicians to effectively manage these patients is hampered by infrequent clinical exposure and shortcomings in pediatric-specific education. Cognitive gaps in EMS clinicians' understanding of the differences between pediatric and adult airway anatomy and respiratory physiology and pathology, variability in the training provided to EMS clinicians, and decay of the psychomotor skills necessary to safely and effectively manage pediatric patients experiencing respiratory emergencies collectively pose significant threats to the quality and safety of care delivered to pediatric patients. NAEMSP recommends: Pediatric airway education should include discussion of the factors that make pediatric airway management challenging. EMS agencies should provide pediatric-specific education that addresses recognition and treatment of pediatric respiratory distress based upon pathophysiology affecting upper airways, lower airways, cardiovascular systems, or extrinsic causes of disordered breathing. Pediatric airway training should also differentiate between hypoxic and hypercapnic respiratory failure. Education should emphasize that the cognitive and psychomotor skills requisite in management of pediatric respiratory emergencies will differ across patient age groups. EMS clinicians should be provided education and training in technology-dependent children and children and youth with special health care needs. EMS clinicians should receive initial and ongoing education and training in pediatric airway and respiratory conditions that emphasizes the principle of using the least invasive most effective strategies to achieve oxygenation and ventilation. Initial and continuing pediatric-focused education should be structured to maintain EMS clinician competency in the assessment and management of pediatric airway and respiratory emergencies and should be provided on a recurring basis to mitigate the decay of EMS clinicians' knowledge and skills that occurs due to infrequent field-based clinical exposure. Integration of clinician education programs with quality management programs is essential for the development and delivery of initial and continuing education intended to help EMS clinicians attain and maintain proficiency in pediatric airway and respiratory management. [ABSTRACT FROM AUTHOR]

The unique challenges of pediatric respiratory and airway emergencies require the development and maintenance of a prehospital quality management program that includes pediatric-focused medical oversight and clinical care expertise, data collection, operational considerations, focused education, and clinician competency evaluation. Medical director oversight must include a focus on pediatric airway and respiratory management and integrate pediatric-specific elements in guideline development, competency assessment, and skills maintenance efforts. EMS agencies are encouraged to collaborate with medical professionals who have expertise in pediatric emergency care to provide support for quality management initiatives in pediatric respiratory distress and airway management. EMS agencies should define quality indicators for pediatric-specific elements in respiratory distress and airway management and benchmark performance based on regional and national standards. EMS agencies should implement both quantitative (objective) and qualitative (subjective) measures of performance to assess competency in pediatric respiratory distress and airway management. EMS agencies choosing to incorporate pediatric endotracheal intubation or supraglottic airway insertion must use pediatric-specific quality management benchmarks and perform focused review of advanced airway management. [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]

Objectives/hypothesis: The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population.Study Design: Retrospective cohort study.Methods: A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference.Results: Twenty-five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy (P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation.Conclusions: For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations.Level Of Evidence: 4 Laryngoscope, 131:1647-1651, 2021. [ABSTRACT FROM AUTHOR]

Background: Adams-Oliver syndrome is characterized by the combination of congenital scalp defects and terminal transverse limb defects. In some instances, cardiovascular malformations and orofacial malformations have been observed. Little is written with regards to the anesthetic management and airway concerns of patients with Adams-Oliver syndrome. Case presentation: A five-year-old female with Adams-Oliver syndrome presented for repeat lower extremity surgery. Airway exam was significant for dysmorphic features, such as hypertelorism, deviated jaw, and retrognathia. Video laryngoscope was utilized for intubation due to the patients retrognathic jaw, cranial deformities, and facial dysmorphism. A vein finder with ultrasound guidance was needed to place the peripheral intravenous line due to her history of difficult intravenous access. The patient was successfully intubated with slight cricoid pressure applied to direct the endotracheal tube smoothly. Surgery and recovery were both unremarkable. Conclusions: Due to varying presentations of Adams-Oliver syndrome, anesthetic and airway management considerations should be carefully assessed prior to surgery. Anesthesiologists must take into consideration possible orofacial abnormalities that may make intubation difficult. Amniotic band syndrome and other limb defects could potentially impact intravenous access as well. [ABSTRACT FROM AUTHOR]

Perioperative care of patients with Xeroderm Pigmentosum (XP), a rare disorder of DNA repair [1,2], presents many anesthetic challenges. Firstly, harmful ultraviolet radiation can be detected in perioperative areas. Also, anesthetic type must be carefully considered, as exposure to volatile anesthetics may hasten the development of neurodegeneration (Masuda et al., 2002; Reitz and Lanz, 1993; Miyazaki et al., 2007; Fjouji et al., 2013) [3-6]. Furthermore, muscle relaxants can produce a prolonged effect (Soen et al., 2006) [7]. Airway management may be difficult secondary to skin changes and growths (Zarrouki et al., 2017; Hajijafari et al., 2014; Meyer, 1982) [8-10]. Even the risk of using imaging modalities should be considered. Given the above exposure risks, we present considerations for preparing to care for patients with XP in the perioperative period and information on where to purchase supplies to prepare the perioperative area.

Background: Most pediatric resuscitator bags are equipped with a positive-pressure relief ("pop-off") valve meant to prevent delivery of excessive pressure. Pop-off valves, however, can lead to adverse events in emergency situations when providers are unaware of their significance.Case Report: A 3-year-old girl with muscular atrophy and a chronic tracheostomy tube was noted to have decreasing oxygen saturations. Paramedics found the patient in cardiac arrest and initiated resuscitative efforts; the patient regained pulses but quickly became pulseless again. There were two more cycles of cardiac arrest followed by return of spontaneous circulation. When she arrived at the emergency department pulses were present. The emergency physician performed bag ventilation and felt no resistance to bag squeezing, but saw no chest rise, and realized the patient was not being ventilated because all of the air was escaping through the pop-off valve. When the valve was closed, it was impossible to perform bag ventilation. She was found to have complete occlusion of her tracheostomy tube; the paramedics had not been ventilating during transport, though were unaware of the occlusion because of the open pop-off valve. Removal of the tracheostomy tube and placement of an endotracheal tube significantly improved ventilation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pop-off valves are common on pediatric resuscitator bags, but often result in insufficient ventilation and oxygenation during emergency airway management. Emergency airway experts recommend that pop-off valves be avoided or deactivated during emergency resuscitation, but this information has not been widely disseminated. [ABSTRACT FROM AUTHOR]

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

Introduction: 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. Areas covered: 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. Expert commentary: 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. [ABSTRACT FROM AUTHOR]

Summary: Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive (“dos”) or negative (“don'ts”) evidence‐based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium‐risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child‐friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%‐2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure. [ABSTRACT FROM AUTHOR]

Background: One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients. Materials and Methods: A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications. Results: Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH 2 O vs. 16.3 ± 4.5 cmH 2 O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat. Conclusion: Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA.

Introduction Congenital airway obstruction is of varied etiology and uncommonly encountered. Prenatal care and imaging have enhanced detection of these abnormalities and allow for multi-disciplinary care planning for airway management at delivery. Despite the availability and advances in prenatal imaging, unanticipated airway obstruction may not be identified until the time of delivery. Methods Case series. Results Four airway emergencies were encountered in the labor and delivery suite over an eight-month period. Clinical history is correlated with autopsy findings. Congenital upper airway and laryngotracheal anomalies are reviewed. Recommendations to improve timely and efficient airway management in the labor and delivery suite are discussed and a protocol for a multi-disciplinary neonatal emergency airway response team is offered for consideration. Conclusions The development and implementation of a multi-disciplinary emergency newborn airway protocol is both realistic and feasible. While it did not improve survivability in our small group, it did reduce response time. It, or a protocol like it, is recommended for institutions caring for high-risk pregnancies and with Neonatal Intensive Care Units with high acuity patients. [ABSTRACT FROM AUTHOR]

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to characterize pediatric out-of-hospital airway management interventions, success rates, and complications in the United States using the 2012 National Emergency Medical Services Information System (NEMSIS) dataset. Methods In 2012, NEMSIS collected data from Emergency Medical Services (EMS) encounters in 40 states. We included all patients less than 18 years of age and identified all patients who had airway interventions including endotracheal intubation (ETI), bag-valve-mask ventilation (BVM), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) and alternate airways (Combitube, King LT, Laryngeal Mask Airway (LMA), esophageal obturator airway, and cricothyroidotomy). Success and complication rates were analyzed and compared across pediatric age groups, by race, ethnicity, clinical condition, and geographic region. Results We identified a total of 949,301 pediatric patient care events in the NEMSIS 2012 dataset. 4.5% had airway management procedures (42,936 events). Invasive airway management or ventilation (ETI, cricothyroidotomy, alternate airway, CPAP/BiPAP, BVM and other ventilation) took place in 1.5% of patient care events (14,107). Of those who had invasive airway management, 29.9% were less than 1 year of age, 58.1% were male, 42.3% were white, and 83.6% were in urban areas. ETI occurred in 3124 of patient care events (329 per 100,000; 95% CI 318–341). Overall success of ETI was 81.1% (95% CI 79.7–82.6). Lower success was noted in patients with cardiac arrest (75.5%, 95% CI 72.6–78.3) and those aged 1–12 months (72.1%, 95% CI 68.3–75.6). Conclusions Out-of-hospital pediatric advanced airway procedures were infrequently performed. Success rates are lowest in patients aged 1–12 months. [ABSTRACT FROM AUTHOR]

Background: One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients. Materials and Methods: A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications. Results: Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH2O vs. 16.3 ± 4.5 cmH2O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat. Conclusion: Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA. [ABSTRACT FROM AUTHOR]

'Anesthesia is nothing, but airway management' or 'Anesthesia is nothing without airway management', perhaps both are true. Airway anatomy and physiology in infants and small children differs markedly from the adults, and so are the problems associated with it. We have to adopt protocols, methods and techniques, specifically for this population. This special article is an overview of the current trends with a special reference to the future perspective in infant and pediatric airway management. [ABSTRACT FROM AUTHOR]

The article presents a study which developed a clinical consensus statement (CCS) for the improvement of pediatric and adult patient care using tracheostomy tube. The study conducted surveys and formal literature search to refine the scope of CCS and identify evidence gaps. The consensus panel made suggestions regarding consensus statements that address topics including emergency management, initial change of tracheostomy tube, and decannulation prerequisites.

Post-extubation laryngospasm is a common upper airway obstruction occurring after tracheal intubation in children. Upper airway surgical procedures increase the incidence of laryngospasm due to airway blood and secretions. The overall incidence of laryngospasm during cleft lip and palate repair is approximately 6%. Abnormal excitation of laryngeal reflexes causes laryngeal muscle contraction resulting in laryngospasm. Unrecognized laryngospasm can lead to severe respiratory compromise and death. It is imperative that anesthesia professionals are proficient in not only recognizing and treating this respiratory complication, but also taking steps to prevent it. This case report will detail a post-extubation laryngospasm after cleft lip and palate repair. [ABSTRACT FROM AUTHOR]

According to different algorithms of airway management, emergency cricothyrotomy is the final step in managing an otherwise not accessible airway. As an alternative to an open surgical procedure, minimally invasive approaches exist. Quicktrach baby™ is a commercially available set for a minimal invasive cricothyrotomy in infants. The set consists of a plastic cannula over a metal needle for direct placement in the trachea. So far, this device has not been evaluated for its intended use. We hypothesize that Quicktrach baby™ allows the establishment of an emergency airway. The aim was to prove that the device is easy to handle and the cricothyrotomy fast to perform. After approval of the local ethics committee, the study was performed on the cadavers of 10 adult rabbits. Cricothyrotomy was performed with Quicktrach baby™. Successful placement, performance time, and complication rate were documented. Possible ventilation with a breathing bag was evaluated. Data are reported as mean and interquartile range. Successful placement of Quicktrach baby™ was possible in all attempts. The placement took 31 [23-43] s. In two cases, a fracture of the cricoid's cartilage was seen. In one animal, damage to the posterior wall mucosa was observed. In all cases, sufficient ventilation was possible. Quicktrach™ baby proved to be a reliable technique. In the animal model, it is easy and fast to perform. Only a few minor complications occurred. Sufficient ventilation was possible in all attempts. [ABSTRACT FROM AUTHOR]

Background: GlideScope laryngoscopy provides a glottic view equal or superior compared to Macintosh laryngoscopy for endotracheal intubation in adult patients. Data evaluating GlideScope laryngoscopy in pediatric patients are lacking. This study compared intubation times of GlideScope laryngoscopy vs Macintosh laryngoscopy in pediatric patients. Methods: Sixty ASA I–III patients, aged 10 years or less, were included in this study. Prior to intubation, airway characteristics were measured, and all patients were given an airway class by a separate anesthesiologist using a Macintosh laryngoscope. Patients were then randomly assigned for endotracheal intubation using a Macintosh laryngoscope or the GlideScope, and intubation time was measured. All blades were investigated for blood traces as a surrogate of laryngeal injury. Results: Demographic data and airway characteristics were not statistically significant different between groups. GlideScope intubation time (14 ± 5 s) was not different from Macintosh intubation time (13 ± 5 s). Blood traces were not observed on Macintosh or GlideScope blades. Conclusion: The GlideScope video laryngoscope is equally suitable to facilitate orotracheal intubation in pediatric patients compared to the Macintosh laryngoscope with respect to intubation time and laryngeal trauma. [ABSTRACT FROM AUTHOR]

Perioperative care of patients with Xeroderm Pigmentosum (XP), a rare disorder of DNA repair [1,2], presents many anesthetic challenges. Firstly, harmful ultraviolet radiation can be detected in perioperative areas. Also, anesthetic type must be carefully considered, as exposure to volatile anesthetics may hasten the development of neurodegeneration (Masuda et al., 2002; Reitz and Lanz, 1993; Miyazaki et al., 2007; Fjouji et al., 2013) [3-6]. Furthermore, muscle relaxants can produce a prolonged effect (Soen et al., 2006) [7]. Airway management may be difficult secondary to skin changes and growths (Zarrouki et al., 2017; Hajijafari et al., 2014; Meyer, 1982) [8-10]. Even the risk of using imaging modalities should be considered. Given the above exposure risks, we present considerations for preparing to care for patients with XP in the perioperative period and information on where to purchase supplies to prepare the perioperative area. • Xerderma pigmentosum (XP) is a rare disease with many anesthetic implications. • UV exposure, difficult airway, and anesthetic choice are some considerations for XP. • Thoughtful preparation of the perioperative area improves safety for these patients. • Supplies for OR preparation can be purchased online with relative ease and low cost. [ABSTRACT FROM AUTHOR]