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Retrospective audit of airway management practices in children with craniocervical pathology
Christa Morrison1, Mary Claire Avanis1, Susanna Ritchie-McLean1
1Department of Anaesthesia, Great Ormond Street Hospital, London, UK.
Insights
Anesthetic management for pediatric patients with halo body orthoses presents challenges, with increased difficulty in airway management and intubation when the halo is in situ. Advanced preparation and skilled anesthetists are crucial for safe perioperative care.
Area of Science:
- Pediatric Anesthesiology
- Neurosurgery
- Orthopedics
Background:
- Craniocervical immobilization with halo body orthoses is essential for pediatric craniocervical junction pathology.
- The impact of halo orthoses on perioperative anesthetic management in children is not well-documented in large studies.
Purpose of the Study:
- To review airway management strategies in children requiring halo body orthoses during general anesthesia.
- To compare airway management before and after halo application.
Main Methods:
- Retrospective review of 90 pediatric patients (<16 years) undergoing halo body orthosis placement (1996-2015).
- Analysis of 269 anesthetic records, comparing pre-halo and halo-in-situ procedures.
- Documentation of airway management techniques, laryngoscopy grades, and intubation success rates.
Main Results:
- Facemask ventilation was successful in all cases, though some required adjuncts.
- Increased incidence of Cormack and Lehane grades 3/4 and higher rates of fiberoptic/videolaryngoscopy intubation with the halo in situ.
- Multiple intubation attempts were more frequent with the halo in situ (15.1%) compared to pre-halo placement (3.4%).
Conclusions:
- Airway management in pediatric patients with cervical spine pathology and halo orthoses is anticipated to be more difficult.
- Factors contributing to difficulty include underlying pathology, restricted neck movement, and the halo device itself.
- Recommendations include advanced preparation and availability of anesthetists skilled in pediatric difficult airway management.
Background:
Craniocervical immobilization using halo body orthoses may be required in the management of children with craniocervical junction pathology. To date, the effect of such immobilization on perioperative anesthetic management has not been addressed in large series.
Aims:
The aim of this study was to review the airway management of children requiring halo body orthoses undergoing general anesthesia.
Methods:
The study was a retrospective case note review from a single institution. The neurosurgical database was interrogated to identify all patients less than 16 years of age that required a halo body orthosis from 1996 to 2015. We used the electronic patient record to identify all procedures performed under general anesthesia for these patients, either for halo application, or with the halo in situ. Details of techniques used for airway management were recorded, and paired data between individuals pre- and post-halo application were compared. Demographic data, diagnosis, and perioperative complications were also recorded.
Results:
We identified 90 children that underwent placement of a halo body orthosis. A total of 269 anesthetic records from these patients were analyzed and classified as pre-halo application, or halo in situ. Facemask ventilation was achieved in all patients, though some required simple airway adjuncts and may have been more difficult in the presence of the halo. Supraglottic airways were used successfully in many patients. There was a significant increase in the number of patients classed as Cormack and Lehane grades 3 or 4 on direct laryngoscopy with the halo in situ compared with before the halo was applied. The incidence of intubation using fiberoptic or videolaryngoscopy was higher with the halo in situ. Multiple intubation attempts were required in 3.4% (1/29) of patients undergoing anesthesia for halo placement compared with 15.1% (11/73) undergoing anesthesia with a halo in situ.
Conclusion:
Airway management in children with cervical spine pathology should be anticipated to be more difficult than the general pediatric population. This is likely to be due to co-existing pathology associated with cervical spine disease in children, limitation of neck movement to prevent further neurological injury, and the halo itself limiting access to the head. We recommend advanced preparation, and ensuring the immediate availability of an anesthetist with skills in managing the pediatric difficult airway to avoid complications in this patient population.
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