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).

Evaluation of a Pre-Filled Table and a Flowchart-Based Algorithm as Cognitive Aids to Reduce Deviations in Dose Calculation for Intraoperative Red Blood Cell Transfusions in Children-An International Web-Based Simulation.

BACKGROUND: Transfusion of red blood cell concentrate can be life-saving, but requires accurate dose calculations in children. AIMS: We tested the hypothesis that cognitive aids would improve identification of the correct recommended volumes and products, according to the German National Transfusion guidelines, in pediatric transfusion scenarios. METHODS: Four online questionnaire-based scenarios, two with hemodynamically stable and two with hemodynamically unstable children, were sent to German and international pediatric anesthetists for completion. In the two stable scenarios, participants were given pre-filled tables that contained all required information. For the two emergency scenarios, existing algorithms were used and required calculation by the user. The results were classified into three categories of deviations from the recommended values (DRV): DRV120 (<80% or >120%), as the acceptable variation; DRV 300 (<33% or >300%), the deviation of concern for potential harm; and DRV 1000 (<10% or >1000%), the excessive deviation with a high probability of harm. RESULTS: A total of 1.458 pediatric anesthetists accessed this simulation questionnaire, and 402 completed questionnaires were available for analysis. A pre-filled tabular aid, avoiding calculations, led to a reduction in deviation rates in the category of DRV120 by 60% for each and of DRV300 by 17% and 20%, respectively. The use of algorithms as aids for unstable emergencies led to a reduction in the deviation rate only for DRV120 (20% and 15% respectively). In contrast, the deviation rates for DRV300 and DRV1000 rose by 37% and 16%, respectively. Participants used higher transfusion thresholds for the emergency case of a 2-year-old compromised child than for the stable case with a patient of the same age (on average, 8.6 g/dL, 95% CI 8.5-8.8 versus 7.1 g/dL, 95% CI 7.0-7.2, p < 0.001) if not supported by our aids. Participants also used a higher transfusion threshold for unstable children aged 3 months than for stable children of the same age (on average, 8.9 g/dL, 95% CI 8.7-9.0 versus 7.9 g/dL, 95% CI 7.7-8.0, p < 0.001). CONCLUSIONS: The use of cognitive aids with precalculated transfusion volumes for determining transfusion doses in children may lead to improved adherence to published recommendations, and could potentially reduce dosing deviations outside those recommended by the German national transfusion guidelines.

[Airway Management in Paediatric Anaesthesia]. / Atemwegsmanagement in der Kinderanästhesie.

Due to their low reserves, hypoxia and cardiac arrest occur rapidly in children. The continuous securing of the airway as well as maintenance of oxygenation and ventilation are of prior importance in paediatric anaesthesia. For this purpose, bag-mask ventilation and the opening of the upper airway must be trained and mastered in particular. As the most important supraglottic device, the laryngeal mask has been evaluated for patients of all ages.

[Perioperative Pain Management in Children]. / Perioperative Schmerztherapie bei Kindern.

Acute pain therapy in children is highly complex. Already preoperatively, the course for a successful therapy is set in the interaction with the child and parents. The goal of the treatment is a satisfied child. This means the use of empathy and therapy planning aimed at a balance between effect and side effect and functionality. Modern concepts are opioid-sparing and procedure-specific. Regional anaesthesia plays a major role, among other things due to excellent safety data. Knowledge of age- and block-specific local anaesthetic dosages is essential. Little is known about pharmacodynamic data of analgesics in children. Although knowledge about pharmacokinetic characteristics is increasing, off-label use of analgesics is inevitable. International databases such as the Kinderformularium provide up-to-date information. When using opioids, rules for safe handling must be followed both in terms of use and prescribing. Non-opioids and adjuvants - individually or in combination - have an established place in perioperative pain management. Non-pharmacological interventions can reduce anxiety and pain. Anxiety is one of the risk factors for chronic postsurgical pain.

[Safe and Appropriate Pharmacotherapy in Paediatric Anaesthesia]. / Sichere und passende Pharmakotherapie in der Kinderanästhesie.

Safe and appropriate pharmacotherapy in children requires knowledge of age-group-specific features regarding pharmacology and drug dosing. In addition, aspects of medication safety must be considered. This review highlights basic principles and discusses key facts; further research in paediatric databases is recommended (www.kinderformularium.de).

The German Guidelines for Medication Safety in Pediatric Emergencies.

Medication errors are a significant threat to the safety of patients of all ages. These errors are more common in children than in adults due to age specific drug dosages, drug dilutions and individual dose calculation based on body weight. In addition, it may be necessary to rapidly administer several potentially harmful or even life-threatening drugs during the emergency situation. It is not possible to provide specialized pediatric emergency teams for every prehospital or intra-hospital emergency and technical resources are frequently not identical to those of a specialized facility further increasing the risk of medication errors. This narrative review of the German Guidelines for Medication Safety in Pediatric Emergencies introduces the main principles for medication safety in pediatric emergencies and the highlights its most important pragmatic measures and recommendations.

Changes in transfusion and fluid therapy practices in severely injured children: an analysis of 5118 children from the TraumaRegister DGU®.

PURPOSE: Trauma is the leading cause of death in children. In adults, blood transfusion and fluid resuscitation protocols changed resulting in a decrease of morbidity and mortality over the past 2 decades. Here, transfusion and fluid resuscitation practices were analysed in severe injured children in Germany. METHODS: Severely injured children (maximum Abbreviated Injury Scale (AIS) ≥ 3) admitted to a certified trauma-centre (TraumaZentrum DGU®) between 2002 and 2017 and registered at the TraumaRegister DGU® were included and assessed regarding blood transfusion rates and fluid therapy. RESULTS: 5,118 children (aged 1-15 years) with a mean ISS 22 were analysed. Blood transfusion rates administered until ICU admission decreased from 18% (2002-2005) to 7% (2014-2017). Children who are transfused are increasingly seriously injured. ISS has increased for transfused children aged 1-15 years (2002-2005: mean 27.7-34.4 in 2014-2017). ISS in non-transfused children has decreased in children aged 1-15 years (2002-2005: mean 19.6 to mean 17.6 in 2014-2017). Mean prehospital fluid administration decreased from 980 to 549 ml without affecting hemodynamic instability. CONCLUSION: Blood transfusion rates and amount of fluid resuscitation decreased in severe injured children over a 16-year period in Germany. Restrictive blood transfusion and fluid management has become common practice in severe injured children. A prehospital restrictive fluid management strategy in severely injured children is not associated with a worsened hemodynamic state, abnormal coagulation or base excess but leads to higher hemoglobin levels.

Going around in circles. Is there a continuing need to use the T-piece circuit in the practice of pediatric anesthesia?

Anesthetic equipment, including breathing circuits, has evolved over time. The T-piece circuit, in its various forms, was designed to meet the needs of its time. As equipment and techniques have moved on, it is timely to consider the place of the T-piece in modern pediatric anesthetic practice. Today the circle system is a ubiquitous part of anesthesia. When integrated with a modern anesthetic machine it offers precise control of ventilation together with continuous monitoring of airway pressure and flow: but at the cost of complexity. In comparison the T-piece offers a simple cheap lightweight design, so ergonomic in use that it almost becomes part of the anesthetist: but lacks the control and the barriers to unsafe use of more sophisticated systems. In addition, it requires high fresh gas flow adding to cost and environmental pollution. This pro-con debate discusses whether there remains a case for continuing to use the T-piece circuit in preference over other options. Possible indications for the T-Piece are discussed together with alternative strategies. The limitations of the circle system, the T-piece, and other alternative (such as self-inflating resuscitator bag) are discussed with respect to pediatric anesthetic practice.

[Prehospital Resuscitation of Children]. / Prähospitale Reanimation von Kindern.

The majority of professionals involved in pre-hospital emergency care do not have explicit paediatric training and have limited experience in the care of life-threatening paediatric emergencies. There is often a fear of being overwhelmed. However, no special paediatric expertise is primarily required to successfully perform resuscitation in children. In addition, the scope of the measures required for successful paediatric resuscitation is on average significantly smaller than for adults. It is essential to know clear and easy-to-implement courses of action, such as those provided by the resuscitation guidelines. For the technical implementation of airway protection, mask-bag ventilation and the laryngeal mask are essential, and for access to the venous system, the intraosseous needle is an aid that overcomes all difficulties almost without exception. With additional support from reference sources, calculation aids and length-related systems, a high level of drug therapy safety can be achieved. In summary, through thorough individual and institutional preparation for paediatric emergencies, safe primary care is feasible by emergency service personnel of any speciality.

Improving Pediatric Drug Safety in Prehospital Emergency Care-10 Years on.

OBJECTIVES: The Pediatric Emergency Ruler (PaedER) is a height-based drug dose recommendation tool that was reported to reduce life-threatening medication errors by 90%. The PaedER was introduced into the Cologne Emergency Medical Service (EMS) in 2008 along with educational measures, publications, and lectures for pediatric drug safety. We reviewed the impact of these continuously ongoing measures on medication errors after 10 years. METHODS: The PaedER was introduced and distributed to all 14 emergency ambulances and 2 helicopters staffed with emergency physicians in the city of Cologne in November 2008. Electronic records and medical protocols of the Cologne EMS over two 20-month periods from March 2007 to October 2008 and March 2018 to October 2019 data sets were retrieved. The administered doses of either intravenous, intraosseous, intranasal, or buccal fentanyl, midazolam, ketamine, or epinephrine were recorded. Primary outcome measure was the rate of severe drug dosing errors with a deviation from the recommended dose of greater than 300%. RESULTS: A total of 59 and 443 drug administrations were analyzed for 2007/08 and 2018/19, respectively. The overall rate of drug dosing errors decreased from 22.0% to 9.9% (P = 0.014; relative risk reduction, 55%). Four of 5 severe dosing errors for epinephrine were avoided (P < 0.021; relative risk reduction, 78%). Documentation of patient's weight increased from 3.2% in 2007/08 to 30.5% in 2018/19 (P < 0.001). CONCLUSIONS: The distribution of the PaedER combined by educational measures significantly reduced the rates of life-threatening medication errors in a large EMS. Those results should motivate further initiatives on pediatric drug safety in prehospital emergency care.

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study.

BACKGROUND: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. CLINICAL TRIAL REGISTRATION: NCT02350348.

Hypopharyngeal Perforation Mimicking Esophageal Atresia: A Case Report of an Extremely Low Birth Weight Infant Emphasizing the Need for Preoperative Endoscopy.

We report a case of an extremely low birth weight premature infant born at 27 weeks of gestation, transferred to our tertiary pediatric referral center for surgical repair of an esophageal atresia. Endoscopic evaluation before the start of surgery revealed a hypopharyngeal perforation, resulting in the false impression of esophageal atresia. If no tracheoesophageal fistula is found during tracheoscopy, esophagoscopy should be done before surgical intervention as the inability to pass a nasogastric tube into the stomach is not sufficiently reliable for a correct diagnosis of esophageal atresia.

Rapid and safe removal of foreign bodies in the upper esophagus in children using an optimized Miller size 3 video laryngoscope blade.

BACKGROUND: Foreign bodies lodged in the upper esophagus in children may result in life-threatening complications, especially with button batteries. Rapid removal is essential to prevent complications. Experts report that extraction with a suitable laryngoscope and a forceps is feasible under general anesthesia, but no further data had been available so far. AIMS: To study foreign body visualization and removal from the upper esophagus in children using a new optimized Miller size 3 blade video laryngoscope. METHODS: This prospective observational study was performed in three pediatric hospitals. The clinical observations were reported anonymously on an electronic spreadsheet after obtaining the informed consent from the parents or guardians. During the observational period from January 2019 to October 2020, all children with a foreign body lodged into the upper esophagus were eligible for participation and 22 cases were included. Main outcome measures were rates of successful removal and complications as well as duration of the procedure. Secondary outcome was subjective assessment regarding the quality of the visualization and the feasibility of the procedure. RESULTS: Success rate was 100% with no complications. Mean intervention and anesthesia times were 5 ± 4 minutes and 26 ± 25 minutes. Quality of visualization of the foreign body was judged as 'excellent' or 'good' in all cases and the feasibility of the procedure as 'without' or 'with little' effort in 95% of all cases. CONCLUSION: The new Miller size 3 video laryngoscope enables rapid, easy, and reliable extraction of foreign bodies when they are located in the upper part of the esophagus. As early removal of esophageal foreign bodies, especially with button batteries, prevents life-threatening complications, we suggest this technique as the first choice of treatment.