Reader response

Myron Yaster MD

Therese Walsh, Consultant Anaesthesia and Pain Medicine, Lead for Paediatric Anaesthesia, Honorary Consultant - Paediatric Pain, Newcastle Hospitals on videolaryngoscopy

I think it’s very important to distinguish VL into direct blades versus hyperangulated blades. The evidence to support use of VL is the first choice in all age groups is clear to me but I rarely see much good evidence yet differentiated into which blade to use. My experience is that unless there is another factor for a difficult anatomy - use a standard blade VL, whichever you are used to so miller/mac. I’ve very much seen use of hyperangulated blades in infants and neonates make the process more complicated, more attempts, create awkward angles, more difficulty with less experience anaesthetic assistances in these age groups get the curve not quite right on the stylet etc. The answers to this as usual is more clinical experience and training for our team, but these are relatively infrequent cases for my centre.

Nicholas Marsden, Anaesthesia fellow, The Royal Children's Hospital Melbourne

A robust airway plan includes steps that we will take to ensure the patient is oxygenated if plans fail. Whether VL is plan A will likely increase over time, due to habitual use and increasing availability. Clearly, where airways are most precarious 'the physiologically/situationally difficult airway' (likely outside of theatre) should mandate VL as plan A. In theatres, VL is probably the future, for better or worse, but if its better for patients, who cares? Regarding DL skills; the 'all equipment fails' argument seems particularly bizarre, as you could make the same infinite argument about any equipment/technology, but we don't, because ultimately its absurd. The arguments against VL seem to be partly professional pride, partly suspicion, partly we're all just luddites at heart. Frankly, what are we so worried about?

Sarah Rebstock MD, UT Southwestern Medical Center on Suzetrigene

I recently used Suzetrigene on two teenage cancer patients with refractory pain that were adult weight. It was quite remarkable in its effectiveness. One kid came off ketamine to be able to go home, have a last Christmas (In June), and be with his siblings. The biggest challenges were knowing what to do with the other medications on board, how to manage them, and it was a challenge to get the medication. It was clearly not on our hospital’s pediatric formulary and it was only available through certain pharmacies. I have heard since that it may be on shortage.

I was repeatedly asked if he would become somnolent if it worked due to the other medication he was already taking for pain. I could not really answer the question, but I suspected that it would not make him somnolent because he was habituated to the other meds. I was right, but we kept him on monitor for the first couple of days of dosing. There really were no side effects that I appreciated in these two patients, I was able to wean them off other things and get them home, so I was grateful for the ability to prescribe the medication. Another question that came up, was: could we increase the dose if necessary. I read the literature several times, but was leery to do anything different than the instructions. Would like to talk more about crossover, if any between receptors at higher doses, and risks with overdose.

I am looking forward to how we might dose children, who are not of adult size and weight, and studying it further in the littles. I would love to get a trial together or be part of one if anyone has connections to be a part of that.

PS from Myron: The time to study this drug in pediatrics is now and I would urge the clinical researchers who read the PAAD to work with the drug company sponsor (Vertex) of this drugto get formal pediatric PK and PD studies done as quickly as is possible. Delaying formal studies will make future studies more difficult or even impossible. Once the anecdotal reports like the one Sarah is posting become more common it will make future studies almost impossible.