Hypoxemia, bradycardia, and multiple laryngoscopy attempts in neonates. Lessons from the NECTARINE study
Stefan Heschl, M.D. PhD, Myron Yaster, MD and Lynne Maxwell, MD
““Those who cannot remember the past are condemned to repeat it”, George Santayana
Today’s PAAD is from the British J of Anesthesia. As promised, we are increasing the number of journals we are covering in the PAAD and are adding new reader/commentators. For those, like me, who don’t know him, Stefan works at the Medical University of Graz, Austria (firstname.lastname@example.org) and is one of the authors of this study and the primary author of today’s PAAD.
Nicola Disma, Katalin Virag, Thomas Riva, et al. Difficult tracheal intubation in neonates and infants.NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study. Br J Anaesth; 2021 Jun;126(6):1173-1181. PMID: 33812665
Today we`ll be reviewing a sub-analysis of the recently published NECTARINE trial(1), focusing on difficult tracheal intubation in neonates. Lynne will be reviewing the key elements of the NECTARINE trial in an upcoming August PAAD.
I (Stefan) was the local PI for NECTARINE at our center. Before discussing this paper, I must congratulate the authors for collecting all that data from so many different sites across a variety of different health care settings.
NECTARINE (NEonate-Children sTudy of Anaesthesia pRactice IN Europe) was a prospective, observational, multicenter cohort study of neonatal and infant anesthesia funded through the ESAIC`s (European Society of Anaesthesiology and Intensive Care) clinical trial network.(1) It was designed to provide information on morbidity and mortality related to anesthesia in patients under 60 weeks postconceptual age. 165 centers from 31 European countries collected data on 5609 patients undergoing 6542 procedures during a 3 month period. Tracheal intubation was planned in 4683 of these procedures and this is the subset reviewed in this study.
Difficult intubation was defined as 2 or more unsuccessful attempts at tracheal intubation by direct laryngoscopy and occurred in 266 patients (271procedures) for an incidence of 5.8%. While successful intubation could ultimately be achieved in 98% of all cases, in 13% of patients with difficult intubation, difficult (but not impossible) mask ventilation was also reported. Also noteworthy is the fact that difficult intubation was not anticipated by the anesthesia provider in more than two thirds of occurrences. Complications occurred in 60% of patients with difficult intubation, 40% experienced oxygen desaturation and 8% of patients became bradycardic.
So, what can we learn from these numbers?
First, difficult intubation in neonates is not rare. The incidence in this study is higher than reported in the Pediatric Difficult Intubation (PeDI) registry, which the authors assume is due to the different reporting (voluntary registry reporting vs. prospective data collection).(2-4) Second, complications arising from difficult intubation, particularly hypoxemia and bradycardia are also not rare and are consistent with previous studies.(5)
Intubation of neonates is not only anatomically challenging but also physiologically difficult. We must therefore undertake every possible step to optimize our first attempt at tracheal intubation. The authors make a strong case for routine use of measures that improve first pass success rate such as videolaryngoscopy and apneic oxygenation techniques in addition to having an experienced anesthesia provider either in charge or at least as backup.
From Myron: Who comes up with these great study names? NECTARINE, I mean Wow! (Stefan reports that the next one, already in the recruiting process, is named BLUBERRY) I was really delighted to have this article in the PAAD because it covers a topic that was close to Ron Litman’s heart. From this and other studies I think it’s pretty clear that it’s long past the time to give up the ghost and use videolaryngoscopy and supplemental O2 during intubation in neonates, the benefit of which have been demonstrated in the VISI trial.(4) Goodbye standard “0” Miller blade.
From Lynne: It should be noted that information about pediatric anesthesia subspecialty training of the providers was not reported and therefore the data could not be analyzed with respect to intubation success related to level of pediatric anesthesia training or experience. Many subsequent laryngoscopy attempts in this population were change of blade and/or use of stylet or bougie rather than videolaryngoscopy. These choices may have been related to the diversity of institutions participating in the NECTARINE study and inavailability of advanced airway equipment.
1. Disma N, Veyckemans F, Virag K, Hansen TG, Becke K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W: Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE). Br J Anaesth 2021; 126: 1157-1172 PMID: 33812668
2. Park R, Peyton JM, Fiadjoe JE, Hunyady AI, Kimball T, Zurakowski D, Kovatsis PG: The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. Br J Anaesth 2017; 119: 984-992 PMID: 29028952
3. Gálvez JA, Acquah S, Ahumada L, Cai L, Polanski M, Wu L, Simpao AF, Tan JM, Wasey J, Fiadjoe JE: Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants: A Single-center, Retrospective Study. Anesthesiology 2019; 131: 830-839 PMID: 31335549
4. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX, Jr., Fiadjoe JE: First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020; 396: 1905-1913 PMID: 33308472
5. Fiadjoe JE, Litman RS: Oxygen supplementation during prolonged tracheal intubation should be the standard of care. Br J Anaesth 2016; 117: 417-418 PMID: 2807752