Background: The laryngeal mask airway Supreme (Supreme) is a new singleuse supraglottic device with gastric access capability now available in all sizes for children. Objectives: To compare the i-gel with the Supreme in children for routine airway maintenance. Materials/Methods: One hundred and seventy children, aged 3 months to 11 years, 5–50 kg in weight, were randomly assigned to receive either the i-gel or the Supreme. The primary outcome measured was airway leak pressure. Secondary outcomes included the following: ease and time for insertion, insertion success rate, fiberoptic grade of view, ease of gastric tube placement, number of airway manipulations, quality of airway during anesthetic maintenance, and complications. Results: A total of 168 patients were assessed for the outcomes. The median (IQR [range]) airway leak pressure for the i-gel was higher than with the Supreme, 20 (18–25 [9–40]) cm H2O vs 17 (14–22 [10–40]) cm H2O, respectively (P = 0.001). There were no differences in the time for device insertion, fiberoptic grade of view, quality of airway, and complications. Median (IQR [range]) time of successful insertion of a gastric tube was faster with the Supreme, 12 (9.2–14.3 [5.2–44.2]) s than with the i-gel, 14 (11.9–19 [6.9–75]) s; P = 0.01. The number of airway manipulations during placement was higher with the i-gel than with the laryngeal mask airway Supreme (12 vs 13 patients), P = 0.02. Conclusions: In infants and children, when a single-use supraglottic device with gastric access capabilities is required, the i-gel demonstrated higher airway leak pressures and can be a useful alternative to the Supreme.

A randomized equivalence trial comparing the i‐gel and laryngeal mask airway Supreme in children

Summary Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

An update on newer pediatric supraglottic airways with recommendations for clinical use

Background Although predictors of laryngeal mask airway failure in adults have been elucidated, there remains a paucity of data regarding laryngeal mask airway failure in children. Methods The authors performed a retrospective database review of all pediatric patients who received a laryngeal mask anesthetic at their institution from 2006 to 2010. Device brands were restricted to LMA Unique™ (Cardinal Health, Dublin, OH) and LMA Classic™ (LMA North America, San Diego, CA), and primary outcome was laryngeal mask failure, defined as any airway event requiring device removal and tracheal intubation. Potential risk factors were analyzed with both univariate and multivariate techniques and included medical history, physical examination, surgical, and anesthetic characteristics. Results Of the 11,910 anesthesia cases performed in the study, 102 cases (0.86%) experienced laryngeal mask failure. Common presenting features of laryngeal mask failures included leak (25%), obstruction (48%), and patient intolerance such as intractable coughing/bucking (11%). Failures occurred before incision in 57% of cases and after incision in 43%. Independent clinical associations included ear/nose/throat surgical procedure, nonoutpatient admission status, prolonged surgical duration, congenital/acquired airway abnormality, and patient transport. Conclusions The findings of the study support the use of the LMA Unique™ and LMA Classic™ as reliable pediatric supraglottic airway devices, demonstrating relatively low failure rates. Predictors of laryngeal mask airway failure in the pediatric surgical population do not overlap with those in the adult population and should therefore be independently considered.

Failure of the Laryngeal Mask Airway Unique™ and Classic™ in the pediatric surgical patient: a study of clinical predictors and outcomes.

The management of children with craniosynostosis is multidisciplinary and has evolved significantly over the past five decades. The treatment is primarily surgical. The anesthetic challenges continue to be the management of massive blood transfusion and prolonged anesthesia in small children, often further complicated by syndrome-specific issues. This two-part review aims to provide an overview of the anesthetic considerations for these children. This first part describes the syndromes associated with craniosynostosis, the provision of services in the UK, surgical techniques, preoperative issues, and the induction and maintenance of anesthesia. The second part of this review will explore hemorrhage control, the use of blood products, metabolic disturbance, and postoperative issues.

/pdf/anesthesia-for-surgery-related-to-craniosynostosis-a-review-3vtogjga4d.pdf

Anesthesia for surgery related to craniosynostosis: a review. Part 1

Perioperative airway problems frequently result in significant morbidity and mortality in children. Therefore, proficiency in airway management is one of the most important key elements in the safe conduct of paediatric anaesthesia. This review includes important anatomical and physiological aspects of the paediatric airway, challenges encountered, and their management with commonly available resources. The importance of early recognition and treatment of anatomical or functional airway obstruction using locally adapted algorithms is highlighted. Children deemed at risk of aspiration require a controlled rapid sequence induction with sufficiently deep anaesthesia, confirmed complete muscle paralysis and intermittent ventilation prior to tracheal intubation. The benefits of a supraglottic airway device and a cuffed tracheal tube in paediatric airway management are discussed. The primary goal of mastering the paediatric airway is to ensure oxygenation and ventilation. This requires intricate knowledge, regular practice and experience.

/pdf/the-paediatric-airway-basic-principles-and-current-52i7z7p5yb.pdf

The paediatric airway Basic principles and current developments

Summary

Background: The i-gelTM is one of the latest commercially available, second-generation supraglottic airway devices (SADs). Specific features include a distal cuff made of a thermoplastic elastomer gel that does not require inflation and a gastric side channel to allow passage of a gastric tube, venting of gas from the stomach, and an early indication of regurgitation. Previous studies in older children and adults have shown that it is a reliable, efficient, and safe device for airway management.



Methods:  We evaluated the i-gelTM in sizes ranging from 1 to 2.5 in children considered suitable for a supraglottic device. We assessed successful rates of insertion, airway leak pressure, position confirmed by fiberoptic laryngoscopy, gastric tube placement, manipulations required, and complications.



Results:  The i-gelTM was used in 154 children over a period of 12 months. The median age [interquartile range (IQR)] was 4 years 11 months (2–7 years), median weight (IQR) 19 kg (13–26), and median (IQR) duration of procedure 29 (30–45) min. First insertion attempt was successful in 93.5% of patients, and second attempt in 5.8%. The median (IQR) time to insertion was 14 (13–16) s. The median (IQR) leak pressure was 20 (15–25) cmH20. Gastric tube placement was successful in 90% of cases. On fiberoptic examination, the vocal cords were visible in 97% of patients. Complications arose in 20% of patients, but the majority were minor. Anesthetists commented that the device had a tendency to displace upward out of the mouth and that extension toward the forehead and flexion toward the feet of the proximal tube altered the quality of the airway. Overall, in seven (4.5%) patients, the device was abandoned and an alternative airway was used.



Conclusions:  Pediatric i-gelTM sizes 1.5–2.5 provided a satisfactory airway during anesthesia for spontaneously breathing infants and children. However, to ensure a clear airway, considerable vigilance is required when fixing the device in the mouth and to avoid the negative effects of flexion of the proximal tubing. The i-gelTM is more expensive than first-generation devices. Whether this additional cost for the potential benefit of greater airway protection is considered acceptable will depend on longer-time evaluation and surveillance to establish overall safety.

A clinical evaluation of the I-gel ™ supraglottic airway device in children

The management of children with craniosynostosis is multidisciplinary and has evolved significantly over the past five decades. The treatment is primarily surgical. The anesthetic challenges continue to be the management of massive blood transfusion and prolonged anesthesia in small children, often further complicated by syndrome-specific issues. This two-part review aims to provide an overview of the anesthetic considerations for these children. The first part described the syndromes associated with craniosynostosis, the provision of services in the UK, surgical techniques, preoperative issues and induction and maintenance of anesthesia. This second part will explore hemorrhage control, the use of blood products, metabolic disturbance and postoperative issues.

Anesthesia for surgery related to craniosynostosis: a review. Part 2

We read with interest the prospective cohort safety study by Nielsonet al. [1]. Thepaperdescribeswhat appears tobea safe process of resource utilisation to improve theatre and postanaesthesia care unit (PACU) efficiency in their centre. For this process tobe transferrable to other hospitals, and indeedother healthcare systems, we requiremore information regarding the ward processes and human factors considerations that are needed to implement thispositivedevelopment. There are currently estimated tobe sevenmillionpatients awaiting elective surgery in England, with approximately 800,000 of these requiring trauma and orthopaedic surgery [2]. In light of this backlog, any proposal that may improve the efficiency of operating theatre lists while maintaining patient safety is to be commended. The authors present predefined selection criteria for patients deemed suitable for bypassing PACU. These criteria appear justified because patients who were transferred straight to the ward did not suffer adverse events and were discharged earlier than patients who required PACU care. It is likely that these positive outcomes were not because the patients were transferred straight to the ward but rather due to careful patient selection. Our first query is how the authors decided on the predefined criteria and, secondly, if they have plans to further validate their scoring system in other centres. They note that a randomised controlled trial may be needed. We are concerned that this may prove impractical with difficulty in randomisation, and to obtain a meaningful patient-centred primary outcome would requiremanypatients for a relatively small intervention. Instead, we propose that this successful trial of bypassing PACUwith carefully selected patients could be individualised to institutions. For this to be possible, more information is needed about the context of this particular Danish hospital and the practicalities of this study. The Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines exist to provide a framework for reporting of system-level work that aims to improve quality, safety and value of healthcare [3], with a particular focus on the context of the study. Without a better understanding of the study’s context, wewould caution against adoption of this intervention as there may be significant unintended consequences. We wonder if the authors considered undertaking a hierarchical task analysis [4] and failure mode effect analysis [5] to explore the likelihood and impact of unintended consequences and their suitable mitigation. In particular, we would like to know how the intervention was received by staff and whether any challenges arose during the implementation. For translation to other centres, the details of the postoperativeward are also important, for example, how the layout of the ward aids monitoring; how often monitoring was performed; did the postoperative analgesic plan change for ward patients and what are the staffing ratios on thepostoperativeward? Finally, this project appears to have been a positive intervention in their centre. Is it now standard practice and used in other centres in Denmark? This study has important implications for changing routine care pathways and we congratulate the authors on the development of a successful pathway to improve operating theatre flowwith nodetriment to patients.

Corinna Hughes

Papers

A clinical evaluation of the I-gel ™ supraglottic airway device in children

Anesthesia for surgery related to craniosynostosis: a review. Part 1

Anesthesia for surgery related to craniosynostosis: a review. Part 2

Bypassing the post‐anaesthesia care unit after elective hip and knee arthroplasty