Sedation versus General Anesthesia for Intubation: Comment.

Abstract

In their retrospective study comparing the outcome of difficult airway management in pediatric patients managed with general anesthesia and sedation, Sequero-Ramos et al.1 found little difference in first intubation attempt success or complications between the two groups. It is noteworthy, however, that 27% of the sedation cohort required conversion to general anesthesia. Why was sedation so unsuccessful in the cohort studied? The details of the sedation techniques were not reported, but these results suggest that some of the sedation techniques may be insufficiently refined to achieve the goal of spontaneous ventilation and compliance with airway management. Additional research is needed to understand whether a greater success rate can be achieved using sedation in the pediatric population.As we seek to investigate sedation techniques for pediatric patients with difficult airways, selection of pharmacologic agents and how they are combined and administered will be an important focus. The human resources available to both manage sedation and secure the airway should also be a focus for investigation. In the original practice guidelines for sedation and analgesia by non-anesthesiologists, there is a clear recommendation that sedation be provided by someone who is not involved with the procedure.2 Specifically, the practice guideline states: “A designated individual, other than the practitioner performing the procedure, should be present to monitor the patient throughout procedures performed with sedation/analgesia. During deep sedation, this individual should have no other responsibilities.” This recommendation was reiterated in the American Society of Anesthesiologists Statement on Granting Privileges for Deep Sedation to Non-Anesthesiologist Professionals.3 Given the unique challenge of deeply sedating pediatric patients to ensure cooperation while maintaining spontaneous ventilation, it is easy to argue for a dedicated sedationist, undistracted by airway management. It is not, however, typical practice to use the available human resources in that fashion.As we design studies to identify a reliable approach to sedation for pediatric difficult airway management, we should heed our own guidance to non-anesthesiologist colleagues. An anesthesia professional, dedicated solely to the administration of sedation and patient monitoring while others focus on airway management, may be essential to achieving an acceptable rate of success.The author declares no competing interests.