Pediatric anesthesia presents unique challenges due to children’s distinct physiological and anatomical characteristics, including variations in drug metabolism, airway structure, and respiratory and circulatory regulation. Despite significant advances in patient safety that have reduced anesthesia-related mortality over recent decades, the declining pediatric population has made specialized training and clinical practice increasingly difficult. This narrative review addresses practical aspects of pediatric anesthesia, emphasizing patient monitoring, airway management, and recent clinical advances. Oxygen supply targets in children require careful titration to ensure adequate tissue oxygenation while avoiding oxygen toxicity and its associated complications, such as bronchopulmonary dysplasia and retinopathy of prematurity. Quantitative monitoring of neuromuscular blockade, such as with train-of-four stimulation, is essential to prevent postoperative respiratory complications. Temperature monitoring is equally critical in pediatric surgery because children and neonates are highly susceptible to intraoperative hypothermia. Airway management in infants and young children is complicated by anatomical differences, and while video laryngoscopy offers advantages, evidence for its benefits in neonates remains inconclusive. Extubation strategies must be individualized, taking into account risks such as laryngospasm and airway obstruction, as both deep and awake extubation have demonstrated comparable safety profiles. Emerging modalities, such as transfontanelle ultrasonography, provide real-time cerebral blood flow assessment and enhance perioperative brain monitoring. Regional anesthesia techniques in neonates and infants reduce exposure to general anesthetics and facilitate faster recovery but require meticulous technique and monitoring to ensure safety. Multidisciplinary collaboration and effective communication with parents are essential to achieving optimal outcomes.

Objectives

We analyzed retrospectively incidence, management, and predictors of difficult intubation, which have been known through practical cases.

Methods

A total of 217 cases of difficult intubation (DI) between 2010 and 2014 were investigated. Risk factors such as age, body mass index, Mallampati score, thyromental distance, degree of mouth opening and range of neck motion, Cormack-Lehane grade, intubation and airway management techniques were investigated. The cases of each department were analyzed and the airway management techniques according to simplified risk scores (SRS) were also investigated.

Results

The average incidence of DI was 0.49%. Patients undergoing surgery in the departments of oro-maxillo-facial surgery (1.35%), ophthalmologic surgery (0.96%), urologic surgery (0.80%), and head and neck surgery of ear-nose-throat (0.62%) showed the higher incidence of DI. Difficult mask ventilation (10 of 217, 4.6%) was occurred with DI. Higher SRS were related to high rates of video laryngoscope use and fiberoptic guided intubation. There was a decrease in the use of McCoy blades after 2013, an increase in the use of video laryngoscope, and a consistent rate of fiberoptic intubation.

Conclusion

It is not easy to check all the predictors of DI in a preanesthetic evaluation and the predictors are not accurate. The role of clinical preparation and practical management is important, and the most important thing is to establish a planned induction strategy. Multiple factors system, such as simplified risk factors should be used to evaluate patients to prepare for appropriate airway management techniques in case of DI.

Citations

• An Association of Predicted/Unpredicted Difficult Intubation with Fibreoptic Bronchoscopic Intubation
  Zeynep ERSOY, Özgür CANBAY
  Turkish Journal of Clinics and Laboratory.2022; 13(3): 340.     CrossRef