Abstract
The expected difficult airway in children is a rare but challenging entity. Publications about pediatric airway management present global recommendations and strategies in order to improve safety and outcome. However, even when a careful plan is implemented according to these fundamental aspects, safety and efficacy may be compromised. The objective of this case report is to alert for the importance of a careful airway planning along with an exhaustive attention to details. A 6 month-year-old child with a complex polymalformative syndrome was scheduled for anti-reflux surgery due to recurrent respiratory infections. A careful plan for airway management was designed, based on airway examination and description of a previous approach with a video laryngoscope. It was decided to schedule two anesthesiologists, one of them experienced in the difficult airway approach. Airway management was planned in order to maintain spontaneous ventilation under inhalational anesthesia with sevoflurane and 100% inspired oxygen fraction. Approaches and sequential steps after failed intubation attempts are described as well as technical difficulties related to material and devices. Given the risk of losing the airway and ventilation it was decided to proceed with the final step of our plan and a surgical tracheostomy was performed. This is an example of how meticulous should be our preparation when planning the airway management in pediatric anesthesia. The presence of another anesthesiologist with expertise in pediatric difficult airway approach, exhaustive description of previous airway approaches and the meticulous revision of the available material including that for invasive procedures should always be kept in mind.
Highlights
Focus on a safe conduct and raising the standards of perioperative care are key elements in pediatric anesthesia
Decision of including two anesthesiologists, including a more experienced one in pediatric difficult airway, and a third available was based on the risks anticipated in airway management
In the absence of studies showing the superiority of using video-laryngoscopy in the pediatric difficult airway, the fiberoptic bronchoscope probably should be the first option when facing the need to intubate a child with a difficult airway in pediatric anesthesia [3]
Summary
Focus on a safe conduct and raising the standards of perioperative care are key elements in pediatric anesthesia. After optimizing patient position and modifying the shape of the tracheal tube with the stylet it was made a second attempt with the video-laryngoscope (Plan A-step 2) It was visualized edema of laryngeal structures and there was a resistance when trying to advance the tube. Given the rapid desaturation 6 and technical difficulties, it was decided to introduce a laryngeal mask I gel® size 1 in order to optimize oxygenation and obtain a conduit for fiberoptic intubation (Plan C-step 1). This approach was complicated by abundant secretions impossible to be suctioned by the smaller fiberscope without working channel (diameter 1.8mm).
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