Airway management issues in pediatric anesthesia
Important differences in airway structures and physiologic processes exist between children and adults. Therefore, airway assessment and management techniques must be tailored to the unique needs of the pediatric population.
The CMPA reviewed its medico-legal cases that closed between 1998 and 2009 that involved airway management of children and adolescents during general anesthesia by anesthesiologists. This review identified the following airway management issues:
In some reviewed cases there was more than one airway management issue.
Identified safety measures
The peer experts consulted on these cases were of the opinion that a number of poor clinical outcomes might have been prevented had the anesthesiologist:
The following legal case illustrates several airway management problems.
A healthy female adolescent (P1, formerly ASA I) with malocclusion presented for an elective Lefort I osteotomy with genioplasty.
After induction of a general anesthesia, the anesthesiologist proceeded with a nasotracheal intubation. He inserted an appropriately-sized RAE tube to the 25 cm mark and fastened it with tape around the head. Having secured the airway, surgery began at 0845 hours. Routine anesthetic monitoring (including an arterial line) was used, as well as a warming blanket.
Controlled hypotension anesthesia was used for the maintenance phase. Approximately 90 minutes into the procedure, the maxillofacial surgeon informed the anesthesiologist that there were air bubbles in the oropharynx. The anaesthesiologist immediately noted that the endotracheal tube was now at 20 cm, which suggested inadvertent partial extubation by the surgeon. Following a momentary drop in oxygen saturation (SaO2) to 55 per cent, the anesthesiologist was able to promptly reintubate and reoxygenate the patient with the same nasotracheal tube. Blood transfusions were required due to considerable intraoperative bleeding. The surgery was otherwise uneventful, and the patient remained normothermic.
At the completion of the surgery approximately 4.5 hours later, the anesthesiologist properly reversed all anesthesia. Spontaneous breathing returned. As the patient awakened, she became agitated and attempted to pull out her nasotracheal tube.When she was able to open her eyes on command approximately 20 minutes after completion of the surgery, the anesthesiologist extubated her. She immediately settled with normal respirations. A sudden onset of profuse bleeding from the patient's mouth and nose prompted the anesthesiologist to alert the surgeon, who recommended waiting before cutting the elastic bands used for the intermaxillary fixation as he believed the extubation was responsible for the bleeding.
Shortly afterwards, the patient developed respiratory difficulties. A partial laryngospasm rapidly evolved, making ventilation difficult. Initial treatment with intravenous lidocaine and a benzodiazepine was ineffective, so the surgeon began removing the elastic bands at the request of the anesthesiologist. Propofol was administered which improved the bagmask ventilation.
Believing the patient's breathing was reestablished, the anesthesiologist recommended the surgeon stop removing the elastic bands. Five minutes later, the patient became asystolic. Despite difficulties due to substantial blood and secretions, the anesthesiologist was able to reintubate the patient with an orotracheal tube after three attempts. Although cardiorespiratory resuscitation was successful, the adolescent suffered permanent neurological damage as a result of cerebral hypoxia. No electronic data was available on the anesthetic monitors during the postextubation period as the anesthesia assistant had inadvertently erased it. Therefore, the SaO2 and end-tidal carbon dioxide (ETCO2) values were not documented on the anesthetic record for the remainder of the emergence phase.
The mother, on behalf of the patient, initiated a legal action alleging the anesthesiologist prematurely extubated her daughter.
Experts for this case
Experts supported the induction, maintenance and monitoring performed by the anesthesiologist. The experts also stated that the anesthesiologist responded promptly and appropriately to the inadvertent intraoperative extubation of the patient, which can occur in this type of surgery.
However, the experts were critical of the following three aspects of the anesthesiologist's care during the emergence phase of anesthesia:
The experts concluded the neurological sequelae suffered by the patient resulted from the premature extubation, which led to the cardiac arrest. Without expert support, the CMPA paid a settlement to the patient and family on behalf of the member anesthesiologist.
Figure 1 shows the chronology of events and an overview of the experts' opinions.
Risk management considerations
To improve clinical outcomes and reduce medico-legal risk, anesthesiologists should consider the following questions, which are based on the expert opinions from all of the medico-legal cases involving pediatric airway management: