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A full-term 2-day-old newborn has been persistently vomiting and has been in the neonatal intensive care unit since birth. After delivery, the baby was vigorous, and had APGAR scores of 9/9. The neonatologists order an abdominal x-ray which reveals multiple air-fluid levels indicative of small bowel obstruction. The surgeons are worried about potential intestinal perforation. They want to proceed to the operating room for an exploratory laporotomy as soon as possible. You are on call and immediately attend to the baby for assessment. You notice severe micrognathia, obvious signs of respiratory distress including tachypnea with indrawing of the chest, and a distended tender abdomen. The baby's oxygen saturation on 2 L·min−1 of oxygen via nasal cannula is 93%. What are your concerns and how would you manage this child's airway?

42.2.1 Why Is a Separate Chapter on Pediatrics Important?

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. Hypoxia quickly led to bradycardia and cardiac arrest.1

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

Ironically, 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 ASA Physical Status 1 and 2.

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

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 a practitioner that deals mostly or exclusively with adults when faced with an ill child for fear that they will do something wrong. The biggest differences are found in the child under 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 settings.

42.2.2 What Is Unique About Pediatric Airway Management?

Variability in equipment sizes, drug dosages, and the propensity of children to be both uncooperative and quickly desaturate make even the most-experienced practitioner wary. A crisis situation is also no time to be calculating ...

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