From Mark Schreiner MD and Dorothea A Markakis, MD, FAAP Interim Chair, Department of Integrated Surgical Care, Chair, Division of Pediatric Anesthesiology , Children’s Institute, Cleveland Clinic on awake SGA insertion
From Mark:
I was delighted to see that awake insertion of supraglottic airways has developed some traction.
The LMA wasn’t approved by the FDA until August 1991 but in 1990, Anne Black helped me get a set from England. The idea struck me that the LMA could be inserted into an awake infant without much resistance and I then waited for the right patient to try it on. In 1991 an infant with Pierre Robin syndrome who had severe airway obstruction was in the NICU (at the time it was directly adjacent to the ORs at CHOP), The neonatologists asked for our help in obtaining a secure airway. I was available (at CHOP we might be available but never “free”) to assess the infant. I inserted a #1 LMA and immediately the infant’s breathing improved. Being of unsound mind and reckless, I then administered thiopental and succinylcholine and then using a homemade light wand(1), easily inserted a 3.0 tracheal tube. Dr. Pina Templeton was outside the NICU when I left and asked me what I’d done. I told her “Pentothal, sux, tube.” I thought she would stroke out. Subsequently, Dorothea Markakis wrote up a case series of similar patients. All were performed under much more controlled experiences.(2)
From Dorothea
Thank you for the insightful review in the March 3 PAAD “Awake Supraglottic Airway Placement in Pediatric Patients”. We are grateful for the work of the Pediatric Difficult Intubation (PeDI) Registry group, including highlighting to our colleagues that awake LMA placement is an excellent way to assure one can ventilate the difficult airway.
Mark Schreiner, Sam Sayson and I first described the technique of insertion of an LMA in 3 awake infants with Robin Sequence at CHOP in a 1992 Anesthesia and Analgesia case series. (2) While the infants were awake, the oropharynx was topicalized and an LMA was inserted. The LMA ensured a patent airway prior to the induction of general anesthesia and in between attempts at tracheal intubation. The LMA was new to our United States practice in 1992, gifted to us by UK colleague Ann Black, and today remains a valuable mainstay in the management of the difficult airway for patients of all ages.
Krucylak CP, Schreiner MS. Orotracheal intubation of an infant with hemifacial microsomia using a modified lighted stylet. Anesthesiology. 1992 Oct;77(4):826-7.
Markakis DA, Sayson SC, Schreiner MS. Insertion of the laryngeal mask airway in awake infants with the Robin sequence. Anesth Analg. 1992 Nov;75(5):822-4.
From Dr. David Adam August, MD Ruby Children's Hospital, West Virginia University, Morgantown, WV on To delay or not to delay: upper respiratory tract infections in children: a focused narrative review
As one creator of the COLDS score, I’m glad it continues to generate interest. To publish the original version, Dr. Lee and I faced some pressure to make it quantitative -- combining points from various categories into a total score. These days, I use it differently. Instead of points, I consider any factor graded as moderate/severe to be a ‘red flag’ that makes proceeding more risky. The magic number of red flags, however, depends upon one’s practice environment. The anesthesia team at a large children’s hospital may routinely anesthetize 3-flag kids, while a solo provider at a smaller outpatient center may postpone 1-flag kids. COLDS helps organize risk-related information, but ultimately the decision about an individual case often depends on logistics: how much support will I have (e.g., at this facility, with this team, at this time of day) if this particular child’s URI causes perioperative airway or respiratory problems?
From Rebecca Lee MD, Mount Sinai Hospital NYC on first case on time starts
My institution recently started really looking at this. It’s a bit frustrating because, while it’s rarely the anesthesiologists “fault,” our multiple bottlenecks are not only late surgeons, but preop assessment taking a long time, “financial holds” at the registration desk, trays not ready or complete, trays that are “sterile” are found contaminated when opened. While all of these are offenders during ALL cases which delay all case on time starts, have the room turn-overed (both surgery and anes side) is also a bottleneck. And a hospital that allows surgeons to book cases for 2-3 hours when historically it takes them 5-6 hours or more. Sadly, the administration is not going to “punish” the high money generators especially as this is an adult hospital that just does peds. But I would have the same argument if this hospital was all adults. With that said, this seems to be easier implemented at ASC type setting where case less cases types so equipment, knowledge required etc is less varied.
Despite staff being forced into overtime and this includes anesthesia teams being paid more, this has not convinced surgeons to book their cases appropriately. One surgeon requested longer block times and to not have another surgeon booked after her and was denied so her room went long. Either the surgeons starting their spines at 8pm when it was booked for 3pm are generating enough money to cover the overtime staff that admin is not looking at or their desire to focus on this is smokes and mirrors. I just don’t understand how patient satisfaction hasn’t played a role either. I’ve seen them complain while waiting for their delayed case to go. I’ve trained at and worked at very efficient places and sadly, I’m just pessimistic that anything will change at particular institutions.
From Elliot Krane, MD, FAAP, FASA, Professor (emeritus), Stanford University School of Medicine
One of the earliest papers to address OR efficiency remains a classic to this day and established Stanford as on the cutting edge of hospital cost cutting. Of course I refer to Brodsky JB, Cost Savings in the Operating Room, Anesthesiology 88:834, 1998, doi: 10.1097/00000542-199803000-00041.
From it I’ll quote: “We have found a simple way to significantly reduce expensive operating room time without jeopardizing patient care. Rather than moving patients on the count of three ("1–2-3" move) as had been our practice, we now count only to two ("1–2" move) … With the acceptance and success of the “move-on-two” maneuver, we have initiated a pilot study of a “move-on-one” maneuver. Initial reports suggest that this can be just as safely and successfully done and will lead to a doubling of efficiency (i.e., saving time and money) over the next fiscal year.”