Reader response

Myron Yaster MD

The emergency Front of the Neck Access (eFONA) PAADs evoked a large number of reader responses…I asked members of the Society for Pediatric Anesthesia’s Quality and Safety and Checklist Committees if we should add this to the PediCrisis app and for their personal views on this topic. Here are some their responses.

David M Polaner, MD, FAAP, Professor of Anesthesiology, University of Washington School of Medicine, Seattle Children’s Hospital

Should we add an algorithm to the PediCrisis app: I think it depends on how it is stated. If you say “consider eFONA if you have training and experience “ I think that is ok, but otherwise I think it’s a bad idea to recommend it as a general next step- those who are not well trained can get into a lot of trouble! And yes, probably scalpel/ bougie technique is better.

Steven R. Tosone, MD, Associate Professor Emeritus of Anesthesiology and Pediatrics, Emory University School of Medicine, Staff Anesthesiologist (retired), Children’s Healthcare of Atlanta – Egleston

After a number of such events over a long career (mostly with kids of varying ages) I came to the conclusion that a surgical airway (formal or semi-formal tracheostomy) is a fool’s errand. First, the decision is only made after the airway is lost/failing and the patient is hypoxic before an incision. It takes too much additional time to access the trachea surgically to resuscitate the patient, leaving everyone involved despairing over the loss of a patient. Even one of my most experienced and able ENT surgeons admitted that it’s just not a feasible approach for such urgency. Knowing apneic oxygenation can support life, regardless of PaCO2, I would favor something to get a catheter into the trachea to insufflate oxygen. This is also something that can be practiced in the lab. I am not sure about commercially available kits these days, though.

Alina Lazar, MD Attending Physician, Anesthesiology, Assistant Professor of Anesthesiology (Pediatric Anesthesiology), Northwestern University Feinberg School of Medicine, Lurie Children’s Hospital

I think there’s more evidence emerging to support using a tracheostomy (rather than a cric per se) with a scalpel–bougie technique in truly extreme situations, even in infants. The Rapid Airway Response team at Lurie Children’s has actually used this approach in very young kids. My colleague Matt Rowland, who leads that team and has spent a lot of time reviewing the recent literature, can provide more info about this.

I also think it’s worth having more discussion about whether e-FONA should be included in PediCrisis. Things are clearly evolving, and even if someone wouldn’t open the app right before doing an e-FONA, having it there could raise awareness of the technique and maybe even drive more interest (and urgency) in training. I’m seeing some institutions start to build protocols around this, and I suspect others will follow their lead (paper attached).

Priti G. Dalal MD FRCA, Director, Division of Pediatric Anesthesiology, Professor, Department of Anesthesiology and Perioperative Medicine, Penn State Health

I have personally done a lifesaving trans tracheal catheter with 16g iv canula connected and attached to a 3-way stop cock connected to high flow wall oxygen tubing, made up emergently in case of an adult with severe angioedema coming into the ED. Also having done multiple mini-trachs (and percutaneous trachs) in my role as specialist registrar in ICU using stab cricothyrotomy incision with scalpel, I think it could be challenging in a child, especially in an infant. The transtracheal catheter is less invasive, faster to perform. In that particular situation I was able to do it within seconds and able to quickly oxygenate and that bought us time to contemplate a definitive airway.

Anna Clebone Ruskin MD, Professor, University of North Carolina

Pedi Crisis contains the information that an attending anesthesiologist would want to access during an emergency. Pedi Crisis has this limited scope so that attendings do not need to wade through extra information to see the needed content. Every word and every checklist added make it more difficult to access the needed information in an emergency. Think of packing for a trip to Mars: the needed items must be on the space shuttle, but add too much and the shuttle will be too crowded to accomplish any tasks. Proposed items and checklists are carefully considered by the committee for available evidence and consistency with widespread practice. Only items and checklists with a broad consensus by the committee are added. Like any textbook, resource, or emergency manual, clinical judgement must be used when accessing Pedi Crisis, as every patient, situation, and setting are different.

Please submit any proposed changes or additions in the following format: “change suggested (including dose if applicable)/reason/evidence/level of evidence (RCT, large database evidence, local practice, etc)/references” and send a copy of the references if possible for the committee to review.

From Neural Foundry

This is brilliant work on the age-stratified approach. The 8-year cutoff for different eFONA techniques really makes practical sense given the anatomical transition point where the cricothyroid membrane becomes more accessible. I ran into a similiar case last year where the surgical vs percutaneous decision paralyzed the team, so having clear age-based protocols upfront could've saved crucial seconds.

From Grant Geissler MD FACS FAAP, Medical Director of Children’s Surgery, Chairman, Performance Improvement and Patient Safety Committee, ACS Level 1 Children’s Surgical Verified Program, Division Head, Pediatric Surgery St Joseph’s Children’s Hospital, Attending Pediatric Thoracic and General Surgeon

As a pediatric surgeon, I am most respectful and appreciative of the effort that you and your colleagues put into the PAAD. Reading Charlie Cote’s response article for the management of the obstructed airway by needle cricothyroidotomy brings back memories of hearing him teach this to residents at Children’s Memorial Hospital when we worked together in Chicago 25 years ago. I have learned many things from my pediatric anesthesia colleagues over the years and continue to do so. Many of the articles your group has presented I have used for deeper dives into our own Pediatric Surgical Performance Improvement and Patient Safety Program at St Joseph’s Hospital in Tampa. Articles addressing risk assessment for patients with viral URIs and for congenital cardiac patients undergoing elective surgical procedures, as well as OR radiation scatter patterns affecting OR personnel are just a few recent examples of the impact your group has had on our pediatric surgical program. A pediatric surgical quality and safety program is incomplete without a firm partnership and free collaboration with our anesthesia colleagues. After 25 years, I am still learning from my friend Dr Cote!

From a pediatric surgeon’s perspective, assistance with eFONA is a rare event. Surgical cut down procedures for eFONA are especially challenging in the 5 year and under age range because of small tracheas, abundant soft tissues, and a high riding cricothyroid membrane. Emergency incisions that are vertical avoid the lateral vessels and allow safer extension of the incision if needed. Experienced surgeons know there is that final tenacious membrane anterior to the trachea to divide before tracheal exposure opens up. Good lighting and a proper shoulder role for hyperextension are essential. If the airway obstruction is anticipated and a surgical expert is scrubbed and ready, a surgical cutdown may proceed as a first option.

From Elizabeth M. Putnam MBBS FRCA, Clinical Associate Professor, Anesthesiology, Director of Simulation for Anesthesiology, Department of Pediatric Anesthesiology, Mott Hospital, Ann Arbor, Michigan

I agree with Dr Cote that the fastest and safest initial approach for eFONA for the unanticipated upper airway obstruction in smaller children is initial large bore needle cricothyrotomy to maintain oxygenation with the least initial procedural risk, allowing time for further help to arrive.

I read the article below, and completely agree with these concerns. Here at the University of Michigan, we use the Jet Ventilation Catheter described, and have the peds and infant sizes, one of each, in every difficult airway bag, in each pediatric OR.

Our anesthesiology simulation instructor faculty teach this technique to every resident during their time at Michigan in the simulation center, as well as refresher session for faculty. As the DAS and ASA move towards scalpel, boogie, tube as first-line for adult eFONA, it is a pertinent reminder that when it comes to airway rescue, peds are not just small adults!

From Trevor Krysak HBSc, MD University of Saskatchewan College of Medicine, PGY-5; Department of Anesthesiology, Perioperative Medicine, and Pain Management

Thanks for sharing this article comparing etomidate and ketamine here. I’m a PGY5 resident in Canada and pursuing my pediatric fellowship next year. Throughout training I have used a lot of ketamine in the ICU and OR for critically ill patients, and also a decent amount of etomidate in the OR but not ICU. I genuinely think etomidate is a great induction drug and have had rock stable inductions with it for very sick patients. There is definitely a lot of varying opinions from my anesthesia staff in regards to it being used due it its perceived increased mortality – which the evidence as you mentioned is back and forth on; especially for a single induction dose.

I read this study the after it was published and was very excited to see a paper in such a prominent journal as an advocate for etomidate… until I looked into the methods and appendices. The doses used in my opinion do not seem equipotent and my usual ketamine doses (especially in the ICU for intubation) are much lower than that used in the study. Ketamine doses were either 2.0 mg/kg, 1.5 mg/kg, or 1.0 mg/kg. Etomidate doses were either 0.3 mg/kg or 0.2 mg/kg. I my practice for an induction with ketamine in a healthy patient may reach between 1.0 and 1.5 mg/kg, but usually not more and in sick patients closer to 0.5 mg/kg. My etomidate doses even for healthy patients I find 0.2mg/kg work for the most part. The decision on what dose to use was up to the doctor based on their opinion and experience.

With that said above, I feel the ketamine doses and etomidate doses were not equipotent to say in doses I would use for critically ill patients and the resulting increase in post-intubation hypotension and vasopressor requirement and potential subsequent increased mortality may be related to my subjective opinion to the higher dose of ketamine used compared to etomidate. Albeit I’m still happy to see a study in thr NEJM not saying etomidate is worse than xyz…

From Robert H. Friesen MD, Emeritus Professor of Anesthesiology, Children’s Hospital Colorado, University of Colorado

Regarding asystole following a single dose of succinylcholine, I had a similar experience to Charlie Cote’s quite early in my practice (late 1970s). Following induction with halothane, the resident, who was preparing to administer succinylcholine to the child prior to intubation, asked me whether atropine should be administered first. I replied that I didn’t think it necessary. I was wrong! Following succinylcholine administration, asystole occurred and lasted for about five seconds. Rhythm returned simultaneously with chest compressions and intubation. The child remained pink throughout (no pulse oximetry in those days). I became a staunch advocate for atropine. A few years later, Lance Lichtor, Blaine Miller, and I demonstrated the benefits of atropine in attenuating the hemodynamic effects of halothane induction. [1,2]

Another mode of administration of succinylcholine in the 1970s (and earlier) was that of an intravenous infusion (“sux drip”), although I don’t remember ever using it on a child. A vial of lyophilized succinylcholine was squirted into a 250 mL bag of fluid and dripped into the patient. The drip rate was controlled manually, and its effect was monitored with a twitch monitor. It was used for brief procedures requiring muscle relaxation when the prolonged effect of curare was not desired. Fortunately, shorter lasting nondepolarizing muscle relaxants were developed and the sux drip was relegated to history.

1. Friesen RH, Lichtor JL. Cardiovascular depression during halothane anesthesia in infants: a study of three induction techniques. Anesth Analg 61:42-45, 1982. PMID: 7198413

2. Miller BR, Friesen RH. Oral atropine premedication in infants attenuates cardiovascular depression during halothane anesthesia. Anesth Analg 67:180-185,1988

From Fernando Franco Cuadrado MD, Pediatric Cardiac Anesthesiologist, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Pediatric cardiac anesthesia is a high-acuity subspecialty characterized by sustained clinical intensity, unpredictable schedules, and a relatively small workforce concentrated in academic medical centers. As described in the article, these features contribute to persistent workforce challenges, particularly when non-clinical responsibilities scale alongside clinical service rather than providing meaningful counterbalance.

These demands exist within a pediatric anesthesia labor market that increasingly offers diverse and flexible non-cardiac practice options. Consequently, entry into and retention within pediatric cardiac anesthesia often reflect factors beyond traditional workforce incentives alone, underscoring the importance of professional motivation and support systems in sustaining engagement within the specialty.

Importantly, the skills acquired early in a pediatric cardiac anesthesia career are highly scalable and transferable. With experience, these skills may mature into broader clinical expertise, inform transitions into other areas of pediatric anesthesiology, or support a sustainable, long-term commitment to cardiac practice. Each of these trajectories represents a legitimate and value-preserving outcome, provided clinician time and expertise are viewed as human capital requiring intentional development.

The current workforce distribution—dominated by early-career and late-career clinicians—raises concerns regarding sustainability and succession planning, but also presents an opportunity to shape these trajectories deliberately. In this context, the pediatric cardiac anesthesia workforce itself represents a critical and underleveraged resource. Functional teams, shared clinical ownership, and structured mentorship can serve as stabilizing mechanisms by supporting skill maturation, professional identity formation, and career longevity.

As demand for pediatric cardiac anesthesia expertise continues to grow, a deliberate focus on mentorship and team-based support represents a practical, near-term strategy to strengthen workforce resilience and create conditions for future growth while maintaining clinical excellence.