Pediatric Anesthesiology 2018 Reviews
Saturday Session 4: AAP Ask the Experts Panel
Reviewed by Zulfiqar Ahmed, MD, FAAP
Anesthesia Associates of Ann Arbor, Ann Arbor MI
On Saturday, March 24th, the fourth session of the day was composed of two early afternoon talks. The first speaker was Debnath Chatterjee, MD (Children’s Hospital Colorado). The topic of his presentation was “Toddlers & Button Batteries: A Deadly Combination”. The learning objectives of his talk were as follows:
- Describe the mechanism of injury following button battery (BB) ingestion, formulate an algorithm for the management of a toddler with suspected BB ingestion.
- Recognize the clinical presentation of an aorto-enteric fistula following BB ingestion; and
- Discuss recent legislation and technological advances aimed at improving the safety profile of lithium batteries.
BB ingestion is a potentially life threatening for children, with a seven-fold increase in BB injury severity between 2003 and 2010. This increase in incidence is due to two changes. First is the manufacturing of larger diameter batteries (20-25 mm) and second is emergence of stronger lithium batteries (3 volt). This has led to a perfect storm. BBs are ubiquitous in every home. They are too easily removed from electronic devices and are large enough to become stuck in the esophagus. BBs cause an iso-thermic hydrolysis reaction resulting in an alkaline caustic injury. The electrolyte rich environment of GI tract favors injury and if un-witnessed, children may be asymptomatic for some time while the injury rapidly worsens. Researchers from the National Button Battery Task Force are investigating several mitigation strategies, including the administration of honey or Carafate until endoscopic removal can be performed.
Jatana et al (Laryngoscope 2017) proposed a triage algorithm for patients suspected of BB ingestion. Once a patient is suspected or witnessed to have ingested a BB, a call should be placed immediately to NBIH (National Battery Ingestion Hotline) 1-800-222-1222 for assistance. If the patient is less then 12 years of age or older and the battery diameter likely more than 12 mm, an x-ray should be immediately obtained without waiting for symptoms. If a child older than 12 years of age swallows a single battery less than 12 mm diameter, then conservative management may be followed, provided the caregivers are reliable. (www.poison.org/battery/guideline).
If the child is stable following BBI, proceed with immediate endoscopic removal under general endotracheal anesthesia (GETA). If the patient is actively bleeding or is clinically unstable, immediate endoscopic removal with surgery/CV surgery present is required. If there is any evidence of esophageal injury, the patient should he admitted, kept nil per os and intravenous antibiotics commenced. CT angiography should be performed to evaluate for aortic injury. Alternatively, an MRI may be considered to determine proximity of injury to aorta. A high index of suspicion for aorto-esophageal fistula must be maintained.
For emergent endoscopic removal, rapid sequence induction and endotracheal intubation with adequate intravenous access is preferred followed by extubation of a fully awake patient.
Although a relatively rare event, aorto-enteric fistula is the most common cause of death following BBI. This complication may present many weeks after BB removal. Often, hematemesis is the first sign and the patient may present with ‘sentinel bleeding’. Exsanguination may occur.
Difficult Tracheal Intubation: Getting It Right the First Time
John Fiadjoe, MD (Children’s Hospital of Philadelphia) delivered the second presentation of the session. He began with the question, “Is anesthesia safe?” Safety in anesthesia often starts with airway management. To illustrate this point, Dr. Fiadjoe presented the results of the Apricot Trial. This paper reports the incidence of severe critical events in pediatric anesthesia. It is a prospective multi-center observational study in 261 hospitals in Europe. It collected data on 30,874 children with a mean age of 6·35 years (SD 4·50). The incidence of perioperative severe critical events was 5·2% (95% CI 5·0–5·5) with an incidence of respiratory critical events of 3·1% (2·9–3·3). Cardiovascular instability occurred in 1·9% (1·7–2·1), with an immediate poor outcome in 5·4% (3·7–7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10,000. This was independent of the type of anesthesia. The common factor in all relevant complications was failed intubation.
The concept of a registry to document and measure airway complications in children was initially proposed in 2011. The Pediatric Difficult Intubation Registry (PeDIR) was formed and data collection via an online database by a nationwide team of collaborators began in 2013. Results have been published in various journals since then. Between August 2012 and January 2015, 1,018 difficult pediatric tracheal intubation encounters were recorded. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients.
When approaching a difficult pediatric airway, three basic techniques should be considered:
- Intubation Techniques
- Oxygenation Techniques
- Rescue Techniques
For intubation techniques, video laryngoscopy (51%) and fiberoptic intubation via a supraglottic airway (59%) have the highest first time success rates in difficult airways. In cases of fiberoptic intubation via supraglottic device, the incidence of hypoxemia in PeDIR was 7% without oxygen insufflation vs. 25% with insufflation.
A few recommendations for videolaryngoscopy were discussed. Grade 2 view has a better chance of success than grade 1 view. Also reverse loading the ET tube on the glidescope stylet and ensuring that the curve of the stylet mimics the curve of the video laryngoscope contributes to improved success rate. Combining techniques such as supraglottic device and fiberoptic intubation increases the chance for a favorable outcome. Interestingly, fiberoptic was the single most important method with the highest success rate when combined with any other techniques.
Addition of nasopharyngeal airway and THRIVE (Transnasal Humidified Rapid Insufflation Ventilatory Exchange) and RAE tube use for oxygen insufflation during the attempt to intubate have proven useful.
For rescue techniques, “Ventrain” is a new device that delivers a predetermined flow of oxygen from a high-pressure source and facilitates expiration by suction (active expiration) hence avoiding barotrauma in patients following needle cricothyroidotomy.
