Fiberoptic, Video Laryngoscope, and Nasal Airway Procedures

In patients with known or suspected difficult airways, advanced airway procedures such as fiberoptic laryngoscopy (under general anesthesia—with and without supraglottic airways—and sometimes in awake patients) as well as video laryngoscopy are invaluable. All may be particularly advantageous for use with patients who have limited or reduced cervical spine movement. Other advantages and disadvantages are addressed in this chapter. Techniques for nasotracheal intubation are also described. Flexible fiberoptic laryngoscopy is a means of indirectly visualizing airway structures by threading a fiberoptic scope with a camera at the end of the scope into the airway. The goal of fiberoptic laryngoscopy is endotracheal intubation using a Seldinger technique, whereby an endotracheal tube is guided into the trachea over the fiberoptic bronchoscope. Fiberoptic endotracheal intubation may be performed through the mouth or nose, or through a supraglottic airway (SGA). The use of the fiberoptic scope through an SGA is an especially useful technique in infants who suffer from airway obstruction at rest (e.g., infants with Pierre Robin syndrome). Video laryngoscopy employs a laryngoscope with a camera at the end of the blade to enable the user to indirectly visualize airway structures.

Neonatal Resuscitation

After birth, the neonate must be immediately examined to evaluate the need for further resuscitation. Presence of an adequate respiratory effort and heart rate is vital, in addition to adequate tone and temperature. Warm, dry, and closely monitor the infant immediately after birth. Give positive pressure ventilation if there are any signs of respiratory distress or bradycardia. Low heart rate in a neonate is almost always due to hypoxia, so establish adequate ventilation as soon as possible in these cases. In cases of continued bradycardia, chest compressions and medication (epinephrine) may be necessary. Following resuscitation, transfer the neonate to an appropriate unit for continued monitoring.

Anesthesia for Neonatal Myelomeningocele

Myelomeningocele, also known as spina bifida aperta (often shortened to the nonspecific name “spina bifida”) is a congenital disorder of the spine. In infants with a myelomeningocele, the neural tube has not closed, and the vertebral arches have not fused during development, leading to spinal cord and meningeal herniation through the skin. Because of the high potential for injury and infection of the exposed spinal cord, which could lead to lifetime disability, these lesions are typically repaired within 24 to 48 hours after birth. A myelomeningocele occurs before day 28 of human fetal development and is an abnormality in which the posterior neural tube closes incompletely. The outcome is a vertebral column deformity, through which the meningeal-lined sac herniates. After the bony defect is created, the hypothesized mechanism of meningeal herniation is that the pulsations of cerebrospinal fluid act progressively to balloon out the spinal cord. If the sac is filled with spinal nerves or the spinal cord, it is known as a myelomeningocele; if the sac is empty, it is called a meningocele.

Peripheral Intravenous Line Access

A peripheral intravenous catheter is used to access a peripheral vein. To start a peripheral intravenous line, identify the site, place a tourniquet, clean the skin, stabilize the vein, and insert the catheter. When a “flash” is obtained, thread off the catheter, connect it to the tubing, and secure. This chapter describes tips for finding common intravenous access sites in children, which are the metacarpal, saphenous, cephalic, median, and scalp veins. These veins vary in size, depth, and difficulty. Metacarpal/dorsal hand veins are on the dorsal aspect of the hand and typically arise from adjacent digital veins and form a network that usually provides several targets for access, although there is significant variation. These veins form the cephalic vein (radial side) and basilic vein (ulnar side) as they converge. The cephalic vein arises from the lateral (radial) side of the dorsal venous network before curving around the wrist to run along the anterolateral forearm, where it is frequently easily accessed. It continues on this course up the arm, but more proximally it is less superficial. The median cubital vein runs from the cephalic vein medially toward the basilic vein diagonally across the antecubital fossa and is reliably present if not always visible. The greater saphenous vein is formed on the foot from the dorsal vein of the great toe and the dorsal venous arch of the foot. It ascends anteriorly to the medial malleolus and superiorly up the medial calf.

Pediatric Complex Regional Pain Syndrome: Stellate Ganglion and Lumbar Sympathetic Blocks

Complex regional pain syndrome (CRPS) is a chronic, localized pain condition following an injury, typically affecting a distal extremity. Although the pathophysiology of CRPS is unclear, multiple mechanisms are implicated, including peripheral and central sensitization as well as sympathetically mediated pain. Peripheral nerve blockade can treat the somatic component of CRPS pain, while sympathetic blockade may alleviate pain that is sympathetically mediated. Signs and symptoms manifest as abnormal sensory, motor, vasomotor, and sudomotor changes that are disproportionate to the inciting event. Early recognition of the signs and symptoms, followed by rapid implementation of a multidisciplinary treatment approach—including physical therapy, psychotherapy, pharmacotherapy, and sympathetic nerve blocks, is a major factor in improving outcome and preventing treatment-resistant CRPS.

Local Anesthetic Systemic Toxicity Treatment

Local anesthetic systemic toxicity is a systemic adverse reaction to the administration of a local anesthetic. Children are at particular risk for local anesthetic systemic toxicity given their smaller body weight. In cases of cardiac arrest from local anesthetic systemic toxicity, prolonged chest compressions or extracardiac membrane oxygenation may be indicated because cardiac toxicity may last for several hours. Under general anesthesia, some of the early central nervous system signs of local anesthetic systemic toxicity, such as altered consciousness and seizures, may be masked, and the first indicator of local anesthetic systemic toxicity may be hemodynamic instability or cardiac arrest. Nevertheless, in a multicenter database of more than 100,000 consecutive pediatric regional anesthetics, local anesthetic systemic toxicity did not occur more often in pediatric patients undergoing regional anesthesia under general anesthesia compared with patients undergoing regional anesthesia awake or under sedation, and was overall very rare (2.2/10,000 and 15.2/10,000, respectively). In cases of cardiac arrest from local anesthetic systemic toxicity, prolonged chest compressions or extracardiac membrane oxygenation (ECMO) may be required because toxicity may last for several hours or more. Aggressive resuscitation and early administration of intralipid are the most important steps.

Anesthesia for Tracheoesophageal Fistula

A tracheoesophageal fistula (TEF) is a communication that is congenital or acquired between the trachea and esophagus. The reported incidence of TEF or esophageal atresia (EA) is roughly one to two per 5,000 live births. The first successful surgery for TEF was in 1939. Presently, owing to progress in surgical techniques, neonatal intensive care, and neonatal anesthesia, the majority of neonates with a TEF/EA who do not have severe associated congenital anomalies are expected to have satisfactory outcomes. Coexisting congenital abnormalities occur in 30 to 50% of patients with TEF/EA. Congenital anomalies are more common in patients with isolated esophageal atresia (65%) compared with isolated tracheoesophageal fistula (10%).

Rigid Bronchoscopy and Surgical Airway Procedures, Foreign Body Aspiration, and Gastric Content Aspiration Management

The difficult airway in pediatric patients is most frequently anticipated because of anatomic anomalies from craniofacial pathology. With the increasing population of surviving premature infants who require prolonged intubation perinatally, chronic issues such as subglottic stenosis are also becoming more common. When dealing with the difficult pediatric airway, preparation and communication are key. It is essential to have a continuous dialogue between the otolaryngologist and the anesthesiologist throughout the perioperative course. When involved with a patient who is likely to have a difficult airway, it is best to involve or consult the pediatric otolaryngologist as early in the process as possible. This chapter outlines the most common invasive techniques for management of the pediatric non-normal difficult airway: rigid bronchoscopy and tracheostomy. This chapter will also review the management of an airway foreign body and aspirated gastric contents.

Pediatric Fluid Management and Infusion

In the pediatric population, cases with significant blood loss represent a small percentage of surgeries. However, when significant blood loss does occur, management of fluids and blood products is critical. Examples of high blood loss pediatric surgeries may include trauma, burns, large tumors, scoliosis repair, craniosynostosis repair, neurosurgery, and cardiac surgery. In this chapter, fluid and blood management, as well as the setup of various types of fluid infusions and infusion pumps, are discussed. Surgical blood loss is particularly hazardous in children, given their low baseline blood volume. Crystalloid can be used initially; however, colloid (e.g., albumin), and blood products must be promptly considered for larger amounts of blood loss, based on clinical judgment and lab measurements. Blood loss and transfusion should additionally be discussed with the surgical team. Normally, mild anemia is tolerated in children when intravascular volume deficits are repleted. In addition to lab values, use clinical indicators including postoperative urinary output, heart rate, respiratory rate, and overall hemodynamic stability to guide transfusion decisions. The development of lactic acidosis is a late sign of inadequate oxygen-carrying capacity.

Infant and Pediatric Cardiopulmonary Resuscitation

High-quality cardiopulmonary resuscitation (CPR) in children with cardiac arrest is vitally important to increase the chance of survival. The rate of return of spontaneous circulation from in-hospital cardiac arrests has improved between 2001 and 2013, from 39% to 77%. In adults, cardiac arrest is most commonly due to primary cardiac causes. In contrast, the cause of pediatric cardiac arrest is often asphyxia resulting in hypoxia. Because of this difference, there is a greater level of importance given to ventilation during infant and pediatric CPR. After recognition of the loss of pulse or blood pressure, quick initiation of CPR is necessary to provide blood flow to vital organs. Ensuring high-quality cardiopulmonary resuscitation in pediatric patients requires knowledge of the appropriate equipment, medications, and procedures. Quick recognition of the loss of spontaneous circulation should trigger an immediate call for help and initiation of chest compressions. Ventilation should be supported, and defibrillation should be performed when the patient is in a shockable rhythm. Epinephrine and other medications may also be required.