Sedation Versus General Anesthesia for Tracheal Intubation in Children With Difficult Airways

A Cohort Study From the Pediatric Difficult Intubation Registry

Luis Sequera-Ramos, M.D.; Elizabeth K. Laverriere, M.D., M.P.H.; Annery G. Garcia-Marcinkiewicz, M.D., M.S.C.E.; Bingqing Zhang, M.P.H., Pete G. Kovatsis, M.D.; John E. Fiadjoe, M.D.

Disclosures

Anesthesiology. 2022;137(4):418-433. 

In This Article

Abstract and Introduction

Abstract

Background: Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of this study was to compare the first-attempt success rate of tracheal intubation during sedated tracheal intubation versus tracheal intubation under general anesthesia. The hypothesis was that sedated intubation would be associated with a lower first-attempt success rate and more complications than general anesthesia.

Methods: This study used data from an international observational registry, the Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. The use of sedation versus general anesthesia for tracheal intubation were compared. The primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and nonsevere and severe complications. Propensity score matching was used with a matching ratio up to 1:15 to reduce bias due to measured confounders.

Results: Between 2017 and 2020, 34 hospitals submitted 1,839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation, and 1,764 patients received general anesthesia. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the general anesthesia group. The rate of first-attempt success of tracheal intubation was 28 of 58 (48.3%) in the sedation group and 250 of 522 (47.9%) in the general anesthesia group (odds ratio, 1.06; 95% CI, 0.60 to 1.87; P = 0.846). The median number of intubations attempts was 2 (interquartile range, 1 to 3) in the sedation group and 2 (interquartile range, 1, 2) in the general anesthesia group. The general anesthesia group had 6 of 522 (1.1%) intubation failures versus 0 of 58 in the sedation group. However, 16 of 58 (27.6%) sedation cases had to be converted to general anesthesia for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low.

Conclusions: Sedation and general anesthesia had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to general anesthesia to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low.

Introduction

The incidence of difficult mask ventilation is approximately 6.6%, and the incidence of difficult tracheal intubation is close to 1.5% in the general pediatric population.[1] Difficult tracheal intubation has been estimated to be three times higher in neonates in a recent European multicenter international study.[2] Difficult intubation can be associated with significant complications including hypoxemia, airway trauma, cardiac arrhythmias, and cardiac arrest.[2,3] Anesthetic strategies to perform tracheal intubation in children with an anticipated difficult airway may differ depending on patient factors, institutional resources, and clinician experience. General anesthesia with volatile or intravenous agents remains the most common approach to perform tracheal intubation in children with difficult airways. However, some anesthesia clinicians prefer intravenous sedation for tracheal intubation.[3] Proponents of sedated intubation tout the maintenance of spontaneous ventilation and the ability to emerge the patient if intubation is impossible as advantages over intubation under general anesthesia. Previous data suggest that controlled ventilation with or without neuromuscular blockade is associated with fewer complications than spontaneous ventilation. A sensitivity analysis in that study suggested that the increased complications were related to airway reactivity during tracheal intubation, suggesting that the anesthetic depth may play a role in complications.[4]

Because sedation for airway management is not a common practice, there remains a knowledge gap about its efficacy and related complications in patients with difficult airways. It is unlikely that any single center would have enough sedated cases to perform a comparative analysis. The Pediatric Difficult Airway (PeDI) Registry is an international registry that prospectively collects data from pediatric patients with difficult airways.[3,5,6] Our study aimed to use data in the Pediatric Difficult Airway Registry to determine whether sedation for tracheal intubation in children with difficult tracheal intubation is associated with a lower first-attempt success rate and more complications than general anesthesia. We hypothesized that sedated intubation would be associated with lower first-attempt success and more complications than general anesthesia. Our study primary outcome was the first-attempt success rate of tracheal intubation.

processing....