Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n¼5609) born at mean (standard deviation [SD]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO 2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]¼1.16; 95% confidence interval [CI], 1.04e1.28

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, 5.1e6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO 2 <90% for 60 s) was reported in 40%. No associated risk factors could be identified among comorbidities, 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.

In 2011 the Hungarian Air Ambulance Nonprofit Limited Company introduced a new Rapid Sequence Intubation standard operating procedure using a template from London’s Air Ambulance. This replaced a previous ad-hoc and unsafe prehospital advanced airway management practice. It was hoped that this would increase clinical standards including internationally comparable results. All Rapid Sequence Intubations performed by the units of the Hungarian Air Ambulance under the new procedure between June 2011 and November 2013 were reviewed in a retrospective database analysis. During this period the air ambulance units completed 4880 missions with 433 intubations performed according to the new procedure. The rate of intubations that were successful on first attempt was 95.4% (413), while intubation was successful overall in 99.1% (429) of the cases; there was no failed airway. 90 complications were noted with 73 (16.9%) patients. Average on scene time was 49 minutes (ranging between: 15–110 minutes). This data shows that it is possible to effectively change a system that was in place for decades by implementing a new robust system that is based on a good template.

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The Hungarian Air Ambulance has recently adopted oxygen supplementation during laryngoscopy, also known as apneic preoxygenation, to prevent desaturation during rapid sequence intubation. Despite its simplicity the nasal cannula method has some limitations relevant to our practice. First, the cannula can dislodge if the head is manipulated during preparation or intubation, especially if nasopharyngeal airways are chosen to maximise preoxygenation. Second, the method is incompatible with continuous nasal suctioning required in severe maxillofacial trauma. Third, if only one oxygen source and one competent assistant is available, a situation common during prehospital missions, the extra tube swap needed for continuous oxygen supplementation makes the procedure more complex and prone to error. We report a new method that provides comparable oxygen supplementation to the nasal cannula method, but at the same time eliminates the problems mentioned above and is easier and quicker to perform. It requires the intubator to cut and insert the tubing of the non-rebreather mask into the nasopharyngeal airway, thus providing direct pharyngeal insufflation. The method is applicable to every patient who has at least one nasopharyngeal airway inserted at the time of laryngoscopy and it only requires a pair of scissors.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0200-0) contains supplementary material, which is available to authorized users.