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A full-term baby is born with an initial APGAR score of 4. While stimulating the neonate, the neonatologist observes a heart rate less than 100 bpm with poor chest movement, and therefore proceeds to intubate the trachea. After two failed attempts with a Miller 0 and 1 blade, with no clear view of the vocal cords, you are called to help with airway management. The neonate is tachypneic with signs of upper airway obstruction. The oxygen saturation is 88% at 10 minutes with an oral airway and continuous positive airway pressure delivered via a bag valve mask. What are your concerns and how would you manage this child’s airway?


Why Is a Separate Chapter on Pediatrics Important?

Airway and respiratory events are the most common complications in pediatric patients undergoing anesthesia.1,2 A large prospective observational study looking at over 30,000 anesthetics found the incidence of critical events to be 5.2%, of which 60% were airway management–related events. Laryngospasm and bronchospasm were the most common, with the highest incidence of complications occurring in neonates and infants.2 These perioperative respiratory events contribute significantly to both morbidity and mortality.3

The Pediatric Perioperative Cardiac Arrest (POCA) Registry is a subdivision of the American Society of Anesthesiologists (ASA) Closed Claims Registry dedicated to pediatrics. In the past, 50% of all cardiac arrests documented in the POCA registry were attributed to respiratory causes, with hypoxemia quickly leading to bradycardia and cardiac arrest.4 Through improvements in technology, cardiac arrest due to difficult or failed airway management has decreased to approximately 25%; however, respiratory causes are still the second most common reason for death and brain damage. The number one cause for death and brain damage is cardiovascular, such as unrecognized hypovolemia.4

A multicenter review of children with known difficult airways demonstrated that greater than two attempts at direct laryngoscopy (DL) is associated with a high failure rate and an increased incidence of severe complications.1 The most common severe complication was cardiac arrest occurring in 2% of children. The most common complication overall was hypoxemia. Although children with an ASA status of 3-5 were at higher individual risk of complications, two-thirds of children suffering perioperative death or brain damage were ASA status 1 and 2. Additionally, a review of 1341 healthy infants undergoing routine intubation for elective procedures found a high incidence of multiple laryngoscopy attempts and associated hypoxemia events, underscoring the need for vigilance when caring for all pediatric patients.5

Adverse respiratory events were more commonly encountered under the care of nonpediatric trained anesthesia practitioners, with 80% of laryngospasm events and 80% of airway obstruction events occurring within this group.6 Furthermore, the PeDI registry data showed that in difficult pediatric airways, pediatric-trained anesthesia practitioners were more likely to be successful in placement of the endotracheal ...

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