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CASE PRESENTATION

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A full-term baby is born with APGAR scores of 4/6. The neonatologist attempts stimulation of the baby and then proceeds with two failed attempts to intubate the trachea with a Miller 0 and 1 blade, with no clear view of the vocal cords. You are immediately called to the NICU to help with airway management. You notice the baby in obvious signs of respiratory distress including tachypnea and upper airway obstruction. The baby's oxygen saturation is 93% with an oral airway and face mask. What are your concerns and how would you manage this child's airway?

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THE BASICS

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Why Is a Separate Chapter on Pediatrics Important?

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The Pediatric Perioperative Cardiac Arrest (POCA) Registry is a subdivision of the ASA Closed Claims Registry specifically dedicated to pediatrics. According to the POCA Registry during the 1970s and 1980s, 50% of all cardiac arrests were due to respiratory causes primarily with hypoxemia quickly leading to bradycardia and cardiac arrest.1 Recently, a multicenter study of 1018 children with difficult airways demonstrated that greater than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with high failure rates and an increased incidence of severe complications.2 The most common severe complication was cardiac arrest occurring in 2% of these children. The most common complication overall was hypoxemia.

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Thanks to the advent of pulse oximetry and better monitoring, and perhaps better medications and equipment, respiratory causes are now the second most common reason for death and brain damage, although inadequate oxygenation continues to account for approximately 25% of all pediatric cardiac arrests. Currently, the number one reason for death and brain damage is cardiovascular causes such as unrecognized hypovolemia.1

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Surprisingly, even though children with ASA Physical Status 3 to 5 are at higher individual risk, two-thirds of children suffering perioperative death or permanent brain damage are with ASA Physical Status 1 and 2.

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Most pediatric anesthesia practitioners are not pediatric specialists; over 80% of all pediatric anesthesia care in the United States is provided in non-pediatric centers as part of a mixed practice, usually for pediatric patients with ASA Physical Status 1 and 2.

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Fortunately, there are more similarities between the pediatric and the adult airway than there are differences. The traditional emphasis on the differences between adults and children is unfortunate, and likely impairs the performance of an anesthesia practitioner that deals mostly or exclusively with adults, when faced with an ill child for fear that they will do something “wrong.” When compared to adults and older children, the biggest differences are found in the child less than 2 years of age. For this reason, this age group will be emphasized. The purpose of this chapter is to provide essential information and recommendations regarding pediatric airway management that is evidence-based, and practical in such ...

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