The ‘Can't Intubate Can't Oxygenate’ scenario in pediatric anesthesia: a comparison of the Melker cricothyroidotomy kit with a scalpel bougie technique

Summary Critical airway incidents in children are a frequent problem in pediatric anesthesia and remain a significant cause of morbidity and mortality. Young children are at particular risk in the perioperative period. Delayed management of airway obstruction can quickly lead to serious complications due to the short apnea tolerance in children. A simple, time critical, and pediatric‐specific airway management approach combined with dedicated teaching, training, and frequent practice will help to reduce airway‐related pediatric morbidity and mortality. There is currently no pediatric‐specific universal framework available to guide practice. Current algorithms are modifications of adult approaches which are often inappropriate because of differences in age‐related anatomy, physiology, and neurodevelopment. A universal and pragmatic approach is required to achieve acceptance across diverse pediatric clinicians, societies, and groups. Such a framework will also help to establish minimum standards for pediatric airway equipment, personnel, and medications whenever pediatric airway management is required.

Section: Framework For the Approach To The Pediatric Airwaymentioning

confidence: 99%

A framework for the management of the pediatric airway

Engelhardt

Fiadjoe

Weiß

et al. 2019

“…Evidence for some practice points was nonexistent or equivocal, leading to no specific recommendation. Literature review found no evidence for superiority of curved over straight laryngoscope blades (17,18), for direct over indirect laryngoscopy (19), or for a needle over a scalpel-based technique for front of neck access (20,21).…”

Section: Airway Algorithmmentioning

confidence: 99%

Implementation of NAP4 emergency airway management recommendations in a quaternary‐level pediatric hospital

Long

Cincotta

Grindlay

et al. 2017

Emergency airway management, particularly outside of the operating room, is associated with a high incidence of life-threatening adverse events. Based on the recommendations of the 4th National Audit Project, we aimed to develop hospital-wide systems changes to improve the safety of emergency airway management. We describe a framework for governance in the form of a hospital airway special interest group. We describe the development and implementation of the following systems changes: 1. A local intubation algorithm modified from the Difficult Airway Society's plan A-B-C-D approach, including clear pathways for airway escalation, and emphasizing the concepts of resuscitation prior to intubation, planning for failure, and avoidance of fixation error. 2. Simplified and standardized airway equipment located in identical airway carts in all critical care areas. 3. A preintubation checklist and equipment template to standardize preparation for airway management. 4. Availability of continuous waveform endtidal capnography in all critical care areas for confirmation of correct endotracheal tube placement. 5. Multidisciplinary team training to address the technical and nontechnical aspects of nonoperating room intubation. In addition, we describe methodology for ongoing monitoring of performance through a quality assurance framework. In conclusion, changes in the process of emergency airway management at a hospital level are feasible through collaboration. Their impact on patient-based outcomes requires further study.

“…Impalpable anatomy necessitates a ‘blind’ approach to the trachea and may result in a tracheotomy instead of a cricothyroidotomy. Evidence suggests that the more distal along the trachea FONA is attempted, the lower the success rate for both cannula and scalpel techniques . Therefore, if the CTM is palpable, and can be approached by a flat enough angle of approach (45° or lower), a cricothyroidotomy is preferred to a tracheotomy.…”

Section: Main Articlementioning

confidence: 99%

“…Remembering that the thyroid cartilage is far less prominent in children, the author recommends aiming for the most cephalad palpable airway structure (below the thyroid cartilage) that still allows for a flat angle of approach. The small size of the CTM in neonates and infants, relative to endotracheal tubes, has led to recommendations that a tracheotomy is preferable to a cricothyroidotomy to avoid damage to the cricoid and thyroid cartilages . Further evidence is required before this suggestion can be endorsed as damage to the trachea would also occur during a tracheotomy.…”

Section: Main Articlementioning

confidence: 99%

An institutional approach to the management of the ‘Can't Intubate, Can't Oxygenate’ emergency in children

Sabato

Long

2016

The 'Can't Intubate Can't Oxygenate' emergency is rare in children. Nevertheless, airway clinicians involved in pediatric airway management must be able to rescue the airway percutaneously through the front of the neck should this situation be encountered. Little evidence exists in children to guide rescue techniques, and extrapolation of adult evidence may be problematic due to anatomical differences. This document reviews the currently available evidence, and presents a practical approach to standardizing equipment, techniques, and training for managing the 'Can't Intubate Can't Oxygenate' emergency in children.