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Airway management issues in pediatric anesthesia
An article for physicians by physicians
Originally published December 2010
P1004-4-E

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:

• difficult intubation, (e.g., in the presence of special facial features or syndromes)
• intraoperative dislodgement of the endotracheal tube
• premature extubation
• laryngospasm
• delay in reintubating the patient
• difficult reintubation
• inadvertent esophageal intubation during difficult emergency reintubation
• aspiration in a non-intubated patient

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:

• Performed an appropriate anesthetic assessment before starting the anesthesia.
• When a difficult airway was anticipated, verified that the following were readily available: adequate equipment (e.g., laryngeal mask airway, fibre optic intubation equipment or other pediatric-specific equipment), appropriate medication, and an experienced assistant.
• Used appropriate monitoring equipment, checked that the anesthesia machines and alarms were functioning properly, and enabled the visual and audible alarms.
• Tailored the induction and ventilation techniques to the child's age and condition, including selecting an appropriately-sized endotracheal tube.
• Promptly recognized and responded to intraoperative difficulties, including calling for assistance when needed.
• Extubated the patient when sufficiently awake and when there were no concerns with the integrity of the airway.
• Considered alternative airway management strategies in life-threatening situations, (e g., attempting fibre optic intubation or evaluating the possibility of a surgical airway).

The following legal case illustrates several airway management problems.

Case study

A healthy female adolescent (P1, formerly ASA I) with malocclusion presented for an elective Lefort I osteotomy with genioplasty.

Induction phase

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.

Maintenance phase

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.

Emergence phase

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:

1. Timing of the extubation
   The decision to extubate a patient is generally a judgment call. However, the experts expressed concern about the management of the extubation for this patient, specifically the timing of the extubation. The anesthesiologist and an operating room team member had differing recollections about the patient's state of wakefulness at the time of extubation. This raised concerns among the experts about whether the patient was sufficiently awake to permit safe extubation. They were of the opinion that the development of the laryngospasm also suggested the patient was not adequately awake at the time. They further stated that agitation is not necessarily an appropriate indication to extubate a patient.
2. Management of the laryngospasm
   The experts believed the cardiorespiratory arrest resulted from the laryngospasm. In particular, the experts were not able to support the medications administered to treat the laryngospasm, the delay in removing the patient's elastic bands and the delay in reintubating the patient.
3. Lack of documentation
   The experts also expressed concern about the incomplete documentation following the laryngospasm, which made it difficult to establish the chronology of events and the onset of hypoxia.

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:

• Are you familiar with pediatric airway anatomy?
• Are you familiar with current clinical practice guidelines for anesthesia airway management, including laryngospasm?
• Do you complete an appropriate anesthetic assessment before starting anesthesia? Based on the child's age and condition, do you determine the most appropriate induction and ventilation techniques, including selecting an appropriately-sized endotracheal tube?
• If a difficult airway is anticipated, do you have a management plan to provide enhanced care if required, and do you verify that adequate equipment, appropriate medication, and an experienced assistant are available?
• Do you use appropriate anesthesia monitoring and properly-functioning equipment with enabled visual and audible alarms?
• Do you recognize the early signs of potential airway problems and do you respond promptly to them?
• Do you consider alternative airway management strategies in life-threatening situations?
• Do you take into consideration any factors that can affect the timing of the extubation, (e.g., age, state of wakefulness, presence of protective airway reflexes, type or length of surgery, surgical site)?
• Do you communicate effectively with other physicians and health care professionals throughout the perioperative period and during emergency situations? Do you seek assistance from a colleague if needed?
• Is your documentation of routine and emergency clinical care accurate, complete, and timely?
• Do you disclose to the parents and/or older child any intubation or anesthesia difficulties encountered during the procedure?