Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines.

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines.

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Kids Voices, the perioperative experience of emergency surgery from children's perspectives: A qualitative study.

OBJECTIVE: The study aimed to better understand children's emergency perioperative experience, a little researched topic. Current literature shows discrepancies between child and adult perceptions for the same healthcare experience. Acquisition of knowledge from the child's perspective can be utilized to improve perioperative care. METHOD: This qualitative study included children (4-15 years) undergoing emergency surgery requiring general anesthesia for manipulation under anesthesia (MUA) and appendicectomy. Recruitment was opportunistic with the aim to recruit a minimum of 50 per surgical subgroup, with 109 children interviewed via telephone postoperatively. Data analysis was performed using qualitative content analysis. Participants varied in terms of age, gender, diagnosis and previous perioperative experience. RESULTS: Qualitative content analysis found three overarching themes in association with the perioperative process: (1) fearful/apprehensive, (2) perception of powerlessness and (3) perception of trust and security. Two overarching themes were found from data relevant to the perioperative environment: (1) poor adaptation of the care environment to the children's needs and (2) positive adaptation of the care environment to the children's needs. CONCLUSION AND PRACTICE IMPLICATIONS: The themes identified provide valuable insight into children's perioperative experience. Findings are of value to stakeholders in healthcare and are expected to inform strategies to optimize the quality of healthcare.

Perioperative intravenous lidocaine use in children.

Perioperative pain management impacts patient morbidity, quality of life, and hospitalization cost. In children, it impacts not only the child, but the whole family. Adjuncts for improved perioperative analgesia continue to be sought to minimize adverse side effects associated with opioids and for those in whom regional or neuraxial anesthesia is not suitable. The use of ketamine and alpha agonists may be useful in these settings but have noted adverse effects including hallucinations, hemodynamic instability, and excessive sedation. One alternative is intravenous lidocaine. Despite its off-label use, intravenous lidocaine has demonstrated anti-neuropathic, anti-hyperalgesic, and anti-inflammatory actions and is an emerging technique. Multiple studies in adults have demonstrated beneficial effects of perioperative intravenous lidocaine including improved perioperative analgesia with reduced postoperative opioid use, improved gastrointestinal function, earlier mobilization, and reduction in hospital length of stay. Despite the limited pediatric literature, some of these findings have been replicated. Large-scale trials providing evidence for the pediatric pharmacokinetics and high-quality safety data with respect to intravenous lidocaine are still however lacking. To date, dose ranges studied in the pediatric population have not been associated with serious side effects and current data suggests perioperative intravenous lidocaine in a subgroup of pediatric surgical patients seems well-tolerated and beneficial.

Is there a role for lung-protective ventilation in healthy children?

Lung-protective ventilation (LPV) has been adopted in the theater environment as a strategy to reduce pulmonary complications under anesthesia. Postoperative pulmonary complications are not infrequent and may have significant implications on the postoperative length of stay as well as the morbidity and mortality of pediatric patients. There is evidence in the adult literature to suggest that intraoperative LPV strategies may reduce the risk of such complications. The utility of LPV strategies in healthy children is not well researched, and the data from critical care studies appear to be conflicting. To ascertain the value of intraoperative LPV in pediatric patients, it is important to understand the pathophysiology of pediatric ventilator-induced lung injury and the basis of LPV strategies. The current evidence in adult and pediatric populations, including pediatric intensive care, is reviewed to gain insight into the role and value of intraoperative LPV for pediatric patients.

Peri-operative steroid management in the paediatric population.

BACKGROUND: Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids. METHODS: A comprehensive literature search was conducted to construct a narrative review. RESULTS: The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population. CONCLUSION: The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.

Incidence and cost of stress ulcer prophylaxis after discharge from the intensive care unit: a retrospective study.

OBJECTIVE: To describe current patterns in initiation and cessation of proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) in intensive care units, and to assess the costs associated with inappropriate (non-evidence-based) SUP. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study in five ICUs in Western Australia. We assessed the medical records of consecutive patients admitted to the ICUs between September 2013 and January 2015. Patients aged < 18 years were excluded. RESULTS: We included 531 patients in the study. Of the 184 patients in whom PPIs were initiated for SUP in the ICU, 90 (48.9%) were still taking the therapy at the time of discharge from hospital. A documented indication for ongoing therapy was present in only nine patients (10%). We assumed a 10-year life expectancy after ICU discharge and that most patients continued taking a PPI, and calculated an additional cost of $180.20 per patient admitted to the ICU. This was based only on unnecessary PPI costs (ignoring costs of managing additional adverse events). The direct cumulative annual cost to the WA health system of PPIs continued unnecessarily for patients at discharge from hospital is estimated to be $250 800 for each year they continue to receive them. CONCLUSION: A substantial proportion of patients prescribed SUP in the ICU continue receiving this therapy at hospital discharge despite no clear indication. In addition to potential adverse clinical effects, this is associated with major direct and indirect cost implications.