Sedation vs General Anesthesia for difficult pediatric airway management
Myron Yaster MD, Lynne Maxwell MD and Melissa Brooks Peterson MD
Regardless of your experience and skills, there are certain patients and cases that when you look at your OR schedule and daily assignment you simply know it’s going to be a maximally challenging and potentially catastrophic day. Near the top of that list are patients with known and anticipated difficult airways. Will you be able to ventilate or intubate? How should you proceed? What’s your backup plan? (Do you have the PediCrisis app open on your phone?)
When faced with these patients it’s crucial to think like a Brit and “stay calm and carry on”. How to do this is very personal…I used to hum the following:
I think Lynn sang the Teddy Bear picnic song (during induction) … until the child was asleep, or until the s—t hit the fan.
Myron Yaster MD
Original article
Luis Sequera-Ramos, Elizabeth K Laverriere, Annery G Garcia-Marcinkiewicz, Bingqing Zhang, Pete G Kovatsis, John E Fiadjoe, PeDI Collaborative. Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry. Anesthesiology. 2022 Oct 1;137(4):418-433 PMID: 35950814
Editorial
Simpao AF, Matava CT, Davidson A. Walk a Tightrope or Burn a Bridge?: Sedation versus General Anesthesia for Intubation of a Pediatric Difficult Airway. Anesthesiology. 2022 Oct 1;137(4):384-386. PMID: 36095290
“In 2012, a special interest group in the Society for Pediatric Anesthesia created the Pediatric Difficult Intubation Registry, an international, multicenter, web-based registry of observational data on pediatric difficult airway management, with the goal of improving the care of these challenging patients.[1-3] The Pediatric Difficult Intubation Collaborative has produced a panoply of clinically relevant findings, and their most recent research sought to answer how these patients fare when managed with sedation versus general anesthesia”.[4] One of us (MBP) is a member of this consortium.
“When confronted with a potentially or known difficult airway, most pediatric anesthesiologists induce general anesthesia, albeit with the goal of maintaining both adequate depth and spontaneous respiration.”[4] Recent evidence suggests that paralysis with a neuromuscular blocking agent may improve first attempt success.[2] “In contrast, there are others who decry general anesthesia (and paralysis) because it will ‘burn the bridge’ of spontaneous ventilation and instead choose to walk the tightrope of sedation that is deep enough to diminish airway responses yet light enough to maintain spontaneous ventilation and reverse course if airway management is too treacherous.”[4]
In today’s PAAD, Sequera-Ramos et al.[5] drew on data from the Pediatric Difficult Intubation registry with the aim of comparing outcomes associated with sedation versus general anesthesia for tracheal intubation in children with difficult airways. Using propensity score matching to address selection bias and other confounders inherent in the analysis of retrospective, observational, real-world clinical data they found the following: sedation is equivalent to general anesthesia, that is, there was no difference in first attempt tracheal intubation success when intubating patients with known difficult airways. On the other hand, about a quarter of the sedation patients had to be “rescued” with general anesthesia. Interestingly, patients in the general anesthesia group had an increased risk of minor airway trauma, epistaxis, and esophageal intubation with immediate recognition than the sedation group.
There are a lot of methodologic and statistical issues with this study most of which are beyond our expertise and space availability to comment on but are discussed in detail in the editorial – and this editorial is excellent, so don’t skip it![4] However, several other issues disturbed us and were not really discussed in the article or the editorial. Specifically: Most of the successful sedation attempts were done in older teenagers in the ICUs and not the ORs, but 75% of the patients managed with sedation were cared for in the OR. What medications were used for sedation and how was the depth of sedation assessed prior to the intubation attempt? Who rated the depth of sedation, and how – as we all know the nuances between deep sedation and a spontaneously breathing general anesthetic are complex at best. Though we are unwilling to throw chum in the water and cause a feeding frenzy, we all know that what many intensivists call sedation is really IV general anesthesia. The intubation failures in the sedation group may have occurred because of airway reactivity or an inadequately anesthetized airway for whatever reason. We suspect the majority of failures are due to inadequate depth of sedation and/or anesthesia. Thus, intubation failed when patients were inadequately sedated, but succeeded when patients were adequately anesthetized. Thus, was deepening the level of sedation to the equivalent of general anesthesia the key to successful intubation after an initial failed attempt with sedation? Finally, I (MY) am unclear if the ICU intubations were performed by the intensivists, or by pediatric anesthesiologists, or dual-trained physicians? In the ICU, if patients failed intubation were they anesthetized in the ICU or transported to the OR? What was the backup for deepening anesthesia in the ICU? Was a surgeon gowned and the patient draped for a possible surgical airway? I (MY) have many more questions than answers.
Ultimately you have to know your own skill sets, expertise, and available equipment/personnel. Would we approach these patients and attempt intubation with sedation? Absolutely not! Either spontaneously breathing, very deep general anesthesia or general anesthesia with paralysis is the way to go. What do you think…what would you do? Send your responses and Myron will post in a future PAAD.
References
1. Fiadjoe, J.E., et al., Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med, 2016. 4(1): p. 37-48.
2. Garcia-Marcinkiewicz, A.G., et al., A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Anesth Analg, 2020. 131(2): p. 469-479.
3. Garcia-Marcinkiewicz, A.G., et al., First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet, 2020. 396(10266): p. 1905-1913.
4. Simpao, A.F., C.T. Matava, and A. Davidson, Walk a Tightrope or Burn a Bridge?: Sedation versus General Anesthesia for Intubation of a Pediatric Difficult Airway. Anesthesiology, 2022. 137(4): p. 384-386.
5. Sequera-Ramos, L., et al., Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry. Anesthesiology, 2022. 137(4): p. 418-433.