ABSTRACT
Management of a pediatric airway can be a challenge, especially for the non-pediatric anesthesiologists. Structured algorithms for an unexpected difficult pediatric airway have been missing so far. A recent step wise algorithm, based on the Difficult Airway society (DAS) adult protocol, is a step in the right direction. There have been some exciting advances in development of pediatric extra-glottic devices for maintaining ventilation, and introduction of pediatric versions of new 'non line of sight' laryngoscopes and optical stylets. The exact role of these devices in routine and emergent situations is still evolving. Recent advances in simulation technology has become a valuable tool in imparting psychomotor and procedural skills to trainees and allied healthcare workers. Moving toward the goal of eliminating serious adverse events during the management of routine and difficult pediatric airway, authors propose that institutions develop a dedicated Difficult Airway Service comprising of a team of experts in advanced airway management.
Subject(s)
Airway Management/methods , Airway Extubation , Airway Management/instrumentation , Airway Management/standards , Airway Management/trends , Anesthesia , Child , Clinical Competence , Forecasting , Humans , Intubation, Intratracheal , Laryngoscopy , PediatricsABSTRACT
BACKGROUND: Convection heating shows most promise in maintaining children's core temperatures under anesthesia. We have previously shown that a modified convection heating technique worked in a mannequin model and sought to establish its safety and effectiveness in a clinical study. METHODS: Children were recruited who were having elective surgery under general anesthesia lasting >90 min. The children were anesthetized and maintained in a room temperature of 21 degrees C. Warming was performed by a 'Bair Hugger' attached to a heat dissipation box, producing turbulent air from multiple outlet holes on its face. A plastic sheet covered the child, was attached to the top of the box, tucked into the sides of the bed and left open at the head end. Temperatures at various sites (air, skin, and core) were continuously monitored using thermistors connected to a datalogger and laptop. Analysis was performed using Excel. RESULTS: The study comprised 40 children ranging in age from 2 days to 12.5 years and weigh 2.5-73 kg. Operations were 'peripheral' (e.g. urethroplasty) lasting 90 min to major laparotomy lasting 590 min. Body surface area uncovered was 5-25%. Skin temperatures rose to a maximum of c. 40 degrees C. Core temperatures rose after a 12-min lag by 0.01-0.04 degrees C x min(-1). In children who became hyperthermic, cooling was readily achieved by turning the heating off and leaving the fan running. CONCLUSIONS: The technique is safe and effective for children throughout the pediatric range. The practice of increasing room temperature above 21 degrees C for elective cases should be abandoned. Continuous monitoring of core temperature is necessary to prevent hyperthermia.
Subject(s)
Anesthesia, General/adverse effects , Body Temperature , Heating/instrumentation , Safety , Child , Child, Preschool , Convection , Elective Surgical Procedures , Female , Heating/adverse effects , Heating/methods , Humans , Infant , Intraoperative Care , MaleSubject(s)
Airway Obstruction/diagnosis , Airway Obstruction/therapy , Head and Neck Neoplasms/diagnosis , Head and Neck Neoplasms/therapy , Lymphangioma, Cystic/diagnosis , Lymphangioma, Cystic/therapy , Prenatal Diagnosis , Teratoma/diagnosis , Teratoma/therapy , Airway Obstruction/congenital , Delivery, Obstetric , Female , Fetal Monitoring , Head and Neck Neoplasms/congenital , Humans , Infant, Newborn , Labor, Obstetric , Lymphangioma, Cystic/congenital , Maternal-Fetal Exchange , Monitoring, Physiologic , Pregnancy , Respiratory Mechanics , Teratoma/congenitalABSTRACT
Foreign body aspiration is a leading cause of death in children 1-3 years old, although mortality is low for children who reach the hospital. Presenting symptoms of an inhaled foreign body depends on time since aspiration. Immediately after inhalation the child starts to cough, wheeze, or have laboured breathing. If the early signs are missed, the child usually presents with fever and other signs and symptoms of chest infection. A plain chest X-ray has relatively low sensitivity and specificity for inhaled foreign body. The gold standard for diagnosis and management of this condition is rigid open tube bronchoscopy under general anaesthesia. For late presentations, time should be taken to fast the child and complete a thorough evaluation before bronchoscopy. The procedure should be performed in a well-equipped room with at least two anaesthesiologists, one with paediatric experience, in attendance. Most experienced anaesthesiologists prefer inhalational rather than intravenous induction of anaesthesia and a ventilating bronchoscope rather than intubation. Equally good results have been reported with spontaneous ventilation or positive pressure ventilation; jet ventilation is not advocated for foreign body removal in children.
