Intubation Technique Research Articles

Tracheal Intubation in Emergency Departments in China: A National Cross-Sectional Survey.

BackgroundTracheal intubation is a necessary but risky procedure performed in emergency departments (EDs) around the world. Relatively high morbidity has been encountered in Chinese EDs, which has raised concerns about peri-intubation ED management. This study aimed to investigate intubation procedures and identify any areas for improvement in Chinese EDs.MethodsThis was a questionnaire-based survey lasting 1 month (March 2021) in 41 tertiary-care hospital EDs in mainland China. The primary outcome was complications associated with intubation. Secondary outcomes were the first-pass success rate and blood pressure variations during intubation. Univariate and binary logistic regression analyses were used to find possible risk factors for first-pass intubation failure.ResultsIn total, 1,020 replies were analyzed out of 1,080 surveys submitted (94.4% response rate). Most patients were elderly men with severe medical conditions like cardiac arrest (24.8%). In total, 97.2% of patients were given preoxygenation, and 48.1% received some form of pretreatment. Induction drugs (e.g., etomidate and ketamine) were less often used: 39.9% of intubations used sedatives, 5.5% used analgesics, and only 5.3% used muscle relaxants. The overall first-pass intubation success rate was 85.7% and was accompanied by a 19.8% adverse event rate. A marked decrease in blood pressure after intubation was also identified.ConclusionThis survey found an 85.7% tracheal intubation first-pass success rate (which is relatively high compared to other countries) and a 19.8% adverse event rate (which is also relatively high). Given the very low rate of using induction medications (5.3% used muscle relaxants), future education should focus on induction drugs and traditional intubation techniques.

Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative

We sought to describe the tracheal intubation technique across a network of children's hospitals and explore the association between intubation technical adjuncts and first-attempt success as well as between laryngoscopy duration and the incidence of hypoxemia. We conducted a prospective observational study in 4 tertiary pediatric emergency departments of the Videography in Pediatric Resuscitation Collaborative. Children undergoing tracheal intubation captured on video were eligible for inclusion. Data on intubator background, patient characteristics, technical characteristics (eg, use of videolaryngoscopy and apneic oxygenation), and procedural outcomes were obtained through a video review. We obtained complete data on first attempts in 494 patients. The first-attempt success rate was 67%, the median laryngoscopy duration was 35 seconds (interquartile range 25 to 40), and hypoxemia occurred in 15% of the patients. Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia. Attempts in which videolaryngoscopy was used for the entire procedure (compared with direct laryngoscopy for the entire procedure) had a longer duration (the difference between the medians was 6 seconds; 95% confidence interval, 1 to 12 seconds). Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts. Among children undergoing tracheal intubation in a group of pediatric emergency departments, first-attempt success occurred in 67% of the patients. Videolaryngoscopy use was associated with longer laryngoscopy durations but was not associated with success or the incidence of hypoxemia.

Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial.

The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.

The Laboratory Diagnostic Profile of SARS−CoV−2 (COVID−19) Patients &amp; Associated Factors

Intubation of a patient with temporomandibular joint ankylosis is a challenge for every anaesthesiologist. Dependable anaesthetic technique is most desired by all anaesthesiologists. The purpose of the present article is to have a brief overview of temporomandibular joint ankylosis, its clinical features, management and to review literature demonstrating various intubation techniques available to an anaesthesiologist while managing patients with temporomandibular joint ankylosis.

Early versus Delayed Intubation and Technique in COVID-19: A Review Article

Background: The novel coronavirus 2019 is the cause of the 2020 pandemic that was announced by the world health organization in March 2020. The coronavirus attacks the respiratory system and causes mild to severe hypoxemia. Therefore, a fraction of COVID-19 patients may need intubation and mechanical ventilation. Methods: We conducted a narrative review by searching for articles that mentioned the time of intubation for COVID-19 patients and intubation techniques in PubMed, Google Scholar, Scopus, the Web of scenic, the Cochrane library, and Embase, as well as manual searching. All the selected reviews and studies were limited to humans and the English language. Results: The first data from China shows that 5% of patients require intubation and mechanical ventilation (MV), and there has been considerable debate about the timing of intubation for patients with acute respiratory failure and the technique of intubation. At first, the specialists recommended early intubation. Although we are more familiar with the pathophysiology of coronavirus, the drawbacks and the benefits of early intubation are still controversial. In addition, the intubation process itself is an aerosol-generating procedure and carries a high risk for patients and health care providers. In this review, we aim to review the previous studies and guidelines recommendations related to the time of intubation and intubation technique for COVID-19 patients. Conclusion: Previous research has suggested that early tracheal intubation should be prioritized in severe COVID-19 patients, whereas other studies advocate late intubation due to poor intubation outcomes and weaning difficulties. However, intubation timing should be based on personalized medicine and case-by-case decision making to ensure the best care and benefit of patients. And relying only on theoretical justification may not have good consequences.

Anesthesia for dental care management in children with dystrophic epidermolysis bullosa

Was to summarize our experience in dental treatment of children with dystrophic epidermolysis bullosa (DEB) under deep intravenous sedation. The study comprised 11 DEB patients aged 2-17 years who received full oral rehabilitation under deep sedation in Hospital Pediatric Dentistry department of the Central Research Institute of Dentistry and Maxillofacial Surgery in 2021-2022. Intravenous induction was used if a child already had venous access installed or it was feasible before sedation. If not the case inhalation induction with sevoflurane was performed for vein catheterization. Sedation was sustained by propofol infusion up to aimed concentration. Both dental treatment and extractions were carried out. In 11 children 37 teeth were treated and 14 extracted. Mean duration of the procedure under deep sedation was 53 min (30-190 min). In two children multiple dental extractions resulted in extensive oral mucosa injury with bullae and erosions formation in vermillion, cheeks, and hard palate areas. No skin injuries, airway obstruction or long-term complications of both anesthesiologic an dental procedure were observed. The paper describes main preventive measures minimizing risks of skin and mucosa adverse events. Intravenous sedation with spontaneous respiration allows full oral rehabilitation in DEB children with minimal risks of skin and mucosal injury associated with intubation techniques when performing described preventive measures. Use of cofferdam is crucial for success and safety of the procedure as it prevents water, dust and dental fragments contamination of oropharynx which is especially important in case of sedation with spontaneous respiration.

Airway management in patients with obesity.

Airway management in patients with obesity remains a complex and evolving topic that is becoming more pertinent given the increasing prevalence of obesity and bariatric surgery worldwide. Obesity is associated with increased morbidity and mortality secondary to anesthetic complications, especially related to airway management. Preoperative assessment is especially vital for the bariatric patient so that potential predictors for a difficult airway can be identified. There are several airway management strategies and techniques for the bariatric population that may help reduce postoperative pulmonary complications. This review aims to discuss assessment of the airway, ideal patient positioning, intubation techniques and devices, apneic oxygenation, optimal ventilation strategies, and extubation and post-anesthesia care.

Ryles tube-guided difficult nasal intubation

Rationale: Nasal intubation is an inevitable procedure in head and neck and oral cavity surgeries. Most of these patients usually present with distorted oral and nasal anatomy. Patient Concerns: The distorted anatomy in these patients makes their airway difficult and there are high chances of nasal bleed while securing the airway nasally. Diagnosis: Ryle's tube guided nasal intubation in a patient with temporomandibular joint derangement posted for bilateral temporomandibular joint arthrocentesis. Interventions: After induction of anaesthesia, we faced difficulty in passing North Pole tube via nasal passage, hence we rail roaded the North Pole tube over a Ryle's tube and successfully secured the airway. Outcomes: This innovative method helped us to secure the airway in this patient. Lessons: This simple technique of using a Ryle's tube as an aid for nasal intubation provides an alternate technique for difficult nasal intubation. Although it may not be the first choice for nasal intubation, this technique can be used as an alternative method in case, the tube could not be negotiated through the nasal passage.

Blind bougie first pass success endotracheal intubation process: An out-of-hospital case report

The blind bougie technique is performed when the epiglottis is visible to the intubator, but the vocal cords cannot be seen (Grade III Cormack-Lehane view). The blind bougie technique for endotracheal intubation is not routinely performed by Critical Care Paramedics for a failed intubation in the prehospital setting. However, at Hamad Medical Corporation Ambulance Service in the State of Qatar, the blind bougie technique is included in their failed airway clinical practice guidelines. This case report aims to describe the rapid sequence induction for intubation process and endotracheal tube placement in an adult trauma patient, presenting with a difficult airway, using the blind bougie technique in the out-of-hospital setting. A 35-year-old male patient was ejected from an all-terrain vehicle following a high-speed accident in the desert. The patient sustained an isolated head injury. Based on the patient’s clinical presentation, he required immediate endotracheal intubation for maintenance and protection of his airway prior to rapid transport to definitive care. Predictors of difficult airway were calculated. Using the blind bougie technique, endotracheal intubation was performed with first pass success. It is recommended that emergency medical services include the blind bougie technique of endotracheal intubation among their difficult airway procedures.

Comparative Efficacy Analysis of Intubation Profile in Airtraq Video Laryngoscope Versus Macintosh Laryngoscope in Simulated Difficult Airway Using Cervical Collar

Aim: Comparative efficacy analysis of laryngoscopes -Airtraq vs macintosh - using Intubation Time and Intubationdifficulty score in simulated difficult airway using cervical collar.Methods: Peculiarity is simulated difficult airway by use of cervical collar. A prospective interventionalrandomizedstudy conducted on 60 adult ASA grade-I&amp;II patients scheduled for surgery in tertiary care center.Tracheal Intubation 1. Group(AVL) Airtraq videolaryngoscope (n=30) 2. Group(ML) Macintoshlaryngoscope(n=30). Parameters observed: 1) Intubation Time- seconds 2) Intubation Difficulty Score (IDS) comprised Numbersof-1. intubation attempts 2.operators 3.alternative intubation techniques, 4. Glottic exposure. 5. paramatriccomparison lifting force required during laryngoscopy, Necessity for external laryngeal pressure, Position of thevocal cords.Results: With airtraq laryngoscope intubation discoursed outcomes intubation time is irrelevant with difficultairway where it is highly associated in case of macintosh laryngoscope. Intubation time &amp; difficulty score iscommentating use of Airtraq laryngoscope.Conclusions: The enhanced visual interiors expedite in such a way that intubation time in Airtraq is not dependenton IDS like Macintosh but on neuromuscular reflexes of performer, commentating the superiority of Airtraq overMacintosh

Comparison between Standard Technique versus Reverse Manoeuvre of Airtraq Insertion for Tracheal Intubation in Lean versus Obese Patients undergoing Surgery under General Anaesthesia: A Randomised Clinical Study

Introduction: Obese patients pose challenge to anaesthesiologist in terms of securing airway due to large tongue and anatomical variations, need a novel tracheal intubation technique to quickly secure airway in obese individuals. The airtraq laryngoscope with reverse technique of insertion is used to secure airway without classical sniffing position. Aim: To compare the two techniques of airtraq insertion, standard and reverse manoeuvre, in lean versus obese patients undergoing surgery under general anaesthesia. Materials and Methods: This randomised clinical study was conducted from July 2012 to January 2014 at Seth GS Medical College and KEM Hospital, Mumbai, Maharasthra, India in a total of 200 American Society of Anaesthesiologists (ASA) I-III undergoing surgery under general anaesthesia. Both lean and obese patients were randomly allocated to each technique. After induction of anaesthesia intubation was performed by an expert anaesthesiologist with each technique (three attempts) were used to intubate trachea. If there was a failure, switch over technique was applied. All the groups were analysed for intubation time, number of attempts, ease of intubation Visual Analogue Scale (VAS), haemodynamics, and complications. Results: Both lean and obese groups were comparable in the airway and demographic characteristics. In lean patients there was no significant difference between intubation time with both standard and reverse manoeuvre. While in obese patients reverse manoeuvre (11.84±1.99 seconds) significantly reduced exposure time by 13 seconds as compared to standard technique (24.02±6.94 seconds), thereby reducing total duration of intubation (26.08±1.16 seconds) as compared to total duration of intubation with standard technique (39.62±8.95 seconds). Lean group were comparable in number of attempts with standard technique (47 1st /3 2nd attempt) and reverse manoeuvre (49 1st /1 2nd attempt). Obese group with reverse manoeuvre all were intubated with first attempt (50 1st) with standard technique (46 1st /1 2nd attempt) and there was switch over from standard to reverse technique in three patients. Both lean and obese groups were comparable in complications with both technique. Conclusion: Reverse manoeuvre proved beneficial in obese patients as it reduced intubation time as compared to standard technique, while lean patients showed no difference.

Comparison of different types of stylets with no-stylet technique for intubation with C-MAC D-Blade® videolaryngoscope in simulated difficult airway: A prospective randomized study.

Objective: The angulated C-MAC D-Blade videolaryngoscope (VL) is designed for difficult intubation and may not be compatible with standard PVC endotracheal tubes (ETTs). This study was planned to compare efficacy of C-MAC, D-Blade VL using ETT with three different stylets versus no-stylet in patients undergoing tracheal intubation with simulated difficult airway. Methods: After obtaining written informed consent and IEC approval, a total of 144 adult patients were allocated to four groups of 36 each using no-stylet or different types of stylets. The four groups were as follows: Group NS: no-stylet; Group CS: C-MAC stylet; Group DS: D-Blade-type stylet; Group HS: hockey-stick shaped stylet. A rigid appropriate-sized Philadelphia cervical collar was placed around the neck to simulate difficult airway, and C-MAC D-Blade VL was used for intubation. The duration of each intubation stage and attempts were evaluated. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22.0 (IBM SPSS Corp.; Armonk, NY, USA), and appropriate tests for different variables were applied. Appropriately, Student’s t test, Chi-square test, Mann–Whitney U test, and one-way ANOVA test were applied. Results: Similar Cormack Lehane grade glottic view was observed in all groups. The number of attempts and duration of intubation were significantly greater using NS group than for other groups. Additional laryngeal manipulation was required in all cases in Group NS, compared to one, zero, and two cases in Groups CS, DS, and HS, respectively (P < .001). Conclusion: Use of Hockey stick shaped stylet, D-Blade-shaped stylet, and C-MAC stylet decreased the total intubation duration in patients with simulated difficult airway.

Experience of using a neuromonitor during thyroid surgery in children

Background. Thyroid surgery is associated with the risk of complications that worsen the course of the postoperative period and lead to disability of patients. One of these complications is damage to the recurrent laryngeal nerve, causing impaired phonation, and in the case of bilateral lesions, respiratory impairment.&#x0D; The aim of this work was to study the features of the technique and the effectiveness of the use of neuromonitoring during operations on the thyroid gland.&#x0D; Materials and methods. The study was conducted on a series of 55 clinical observations of thyroid diseases in children. Intraoperative monitoring was performed using the Inomed C2 Nerve Monitor, which records the action potential on the vocal folds caused by electrical stimulation of the recurrent laryngeal nerve.&#x0D; Results. In 52 cases, no decrease in the amplitude of the neuromonitor signal was observed during surgical interventions. In two cases, intraoperatively, a decrease in the signal amplitude associated with excessive traction of the nerve was revealed. Another observation noted the absence of a signal at the end of the operation and the preservation of the mobility of the vocal cords in the postoperative period, probably due to technical errors in performing intraoperative monitoring. In one patient, during the operation, changes in the neuromonitor signal did not occur, but after surgery, a violation of the vocal function was noted, which fully recovered within 3 months. In all likelihood, these changes are due to the technique of tracheal intubation.&#x0D; Conclusions. Neuromonitoring is an additional method for finding the recurrent laryngeal nerve, but in no way replaces the need for delicate anatomical identification of the latter.

Tube tip in pharynx-a conduit for awake oral intubation in patients with extremely restricted mouth opening.

Awake flexible bronchoscope-guided intubation is challenging in patients with extremely limited mouth opening (when there is inadequate space for an oropharyngeal airway), especially when nasal access is unavailable. Alternatives include awake front of neck access, which is an invasive procedure and not suitable for elective surgery. We present a novel technique to facilitate flexible bronchoscope-guided oral intubation in these patients. Tube tip in pharynx (TTIP) is a technique for establishing a patent airway if ventilation is difficult or has failed using a face mask, supraglottic airway, or endotracheal tube. The technique involves placing the tip of the endotracheal tube in the pharynx, 10-14 cm past the teeth, filling the cuff with air, closing the mouth and nose of the patient, and then initiating ventilation. The TTIP method thus combines the function of an oropharyngeal airway and a face mask akin to a supraglottic airway device, but is more flexible with regard to insertion depth and cuff inflation and demands only minimal mouth opening. We have adapted the TTIP technique for awake flexible bronchoscope-guided oral intubation and report the technique illustrated with three cases where mouth opening was so restricted that it precluded insertion of an oropharyngeal airway. By placing an endotracheal tube with the tip in the pharynx, TTIP can establish a conduit for awake oral flexible bronchoscope-guided intubation in patients with extremely limited mouth opening and unavailable nasal access. This technique requires equipment that is readily available and may help avoid unnecessary awake tracheostomy.

Anesthesia Management in Intramural Uterine Myoma and Obesity Morbid Patients Who Underwent Myomectomy Perlaparatomy

Introduction. Obesity is a condition that increases the challenges in the surgical process. Obesity increases the risk of sleep apnea and affects anaesthetics. This case report aims to discuss the management of anaesthesia in a patient with morbid obesity.&#x0D; Case. Female, 26 years old, with intramural uterine myoma and morbid obesity, will undergo myomectomy per laparotomy with ASA II physical status, performed anaesthesia with general anaesthesia intubation technique using the anaesthetic agent Propofol 1-2.5 mg/kg titration until the patient falls asleep, fentanyl 1-2 mcg/kg, then the patient was intubated in a ramped position with sleep non-apnea. After it was confirmed that the ETT was entered, 30 mg of a muscle relaxant (atracurium) was added. The operation lasts 1 hour 30 minutes, with a bleeding 250 cc, hemodynamically stable.&#x0D; Conclusion. Morbid obesity has extraordinary implications for anaesthetic management. Various considerations for patients with morbid obesity are needed starting from the preoperative, intraoperative, to postoperative periods. Regional anaesthesia is preferred because the physiological function of unhealthy obese patients is impaired due to excess body weight. Selection of anaesthetic agent and calculation of drug dose is crucial to know because there is a change in the volume of distribution. The pharmacokinetics of most general anaesthetics are affected by the adipose tissue mass, produce a prolonged drug effect, and less predictable.

Randomised controlled trial in cadavers investigating methods for intubation via a supraglottic airway device: Comparison of flexible airway scope guided versus a retrograde technique.

A supraglottic airway device (SAD) may be utilised for rescue re-oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in-situ SAD. A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000995875). Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2s (standard deviation 8.8) in the FAS group compared with 52.9s (standard deviation 11.7) in the RIT group; a difference of 34.7s (95% confidence interval 27.1-42.3, P < 0.001). All intubations were completed within 2min and there were no equipment failures or evidence of airway trauma. Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.

A Novel Special-shaped Stylet Technique for Intubation with GlideScope® Video Laryngoscope Devices

A Novel Special-shaped Stylet Technique for Intubation with GlideScope® Video Laryngoscope Devices

El-Ganzouri multivariate risk index based airway management in head and neck cancer patients: A retrospective analysis of 1000 patients in a tertiary care center.

Background and Aims:Intubation in head and neck carcinoma (HNC) is difficult due to many reasons. Various guidelines recommend strategies for airway management in such anticipated difficult airway cases. However, literature is limited on airway management planning as per the level of difficulty based on airway assessment in these patients. EL-Ganzouri risk index (EGRI) has been proposed to aid in making airway management plan in HNC cases by some authors. This retrospective study was conducted to look at the data related to the pre-anesthetic airway assessment and the airway management plan executed by the anesthesiologists in 1000 patients of HNC in the previous nearly four years in order to determine how the choices made conformed to EGRI scores.Material and Methods:Records of all the patients with oral cancer posted for surgery over four years from January 2014 to December 2017 were retrospectively analyzed for preoperative airway assessment using El Ganzouri risk index assessment (EGRI), the intraoperative technique for nasotracheal intubation, airway management plan, and any intraoperative complications.Results:The risk of predicted airway difficulty was low (EGRI <4) in 38 patients and was high in the rest. The EGRI score was higher in the FOB group [4-9] as compared to DL [2-3] and VL [1-6]. The patients with EGRI >7 were intubated awake and those with EGRI <7 were intubated under general anesthesia (79.8%). Overall, the technique of choice for intubation was fibreoptic bronchoscopy (54%) followed by video laryngoscopy (42.6%).Conclusion:The airway management plan used in a tertiary care cancer center conformed to the approach suggested by the multivariate El Ganzouri risk index (EGRI). EGRI appears to be a useful means to ascertain the appropriate strategies for intubation in head and neck cancer patients.

Airway patency in children for dental therapeutic procedures in ambulatory practice

This article presents a literature review of basic concepts of artificial airway patency in children during anesthetic management for prolonged dental procedures in outpatient surgery (MedLine, PubMed). The following considers the necessity to protect airways from the moment of onset of deep sedation, when verbal contact with a child is not always adequate, the le-vel of reflex activity is reduced, and vital functions control is not complete yet without additional supporting mechanisms. Airway patency management and selection algorithms are given depen-ding on various factors, such as the duration and invasiveness of dental intervention, the characteristics of the child’s anatomy, and concomitant pathologies, as well as associated emergency conditions with a strategy for their prevention. Comparative cha-racteristics of the use of laryngeal devices and various intubation techniques in the aspect of pediatric dentistry have been carried out. A separate paragraph in the article highlights the methods of monitoring in the operating theatre and the strategy of the Difficult Airway Society, the support and implementation of which is mandatory in any private structures of pediatric outpatient anesthesia practice in Europe and America.

Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study

Background and objectiveManagement of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation. DesignRetrospective cohort study. SettingTertiary Children's Hospital. Participants6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed. Exclusion criteria: age > 18 years, endotracheal tube or tracheostomy in-situ. Methods/interventionsPatients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets. ResultsOf the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without. ConclusionDespite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.