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LPCH Anesthesia: Difficult Airway Management Protocol Goal: Develop an interdisciplinary team approach to the safe management of patients

with known and unknown difficult airways scheduled for procedures or imaging requiring anesthesia. PREAnticipated Difficult Airway/Known Difficult INDUCTION Airway

Surgical/Primary team to: Identify case as potential difficult airway when case is booked. Clinic Scheduler checks Difficult Intubation box under the Anesthesia Alert section on the Scheduling/Pre-Cert form PICU/NICU bed requested if indicated Anesthesia Scheduler to: Identify case on OR schedule as Difficult Airway Schedule case before Noon Schedule case at a time when ENT back-up will be available on premises if needed Schedule case as single-coverage for anesthesia & alert anesthesiologist before noon the day prior to case

Anesthesiologist to: Identify who is available to assist from Difficult Airway Team. Scheduler may need to cover their room. Identify who will be available as ENT back-up and how to contact them. Alert ENT fellow or attending to case if they are not primary service.

Anesthesia Tech to: Ensure availabilit y of difficult airway cart with appropria te size and functional equipmen t Circulating RN to: Pre Op RN to: Verify patient dispositi on and confirm bed available if ICU planned. Identify the number for ENT back-up prior to induction . Call primary service to OR for induction . Be at bedside for induction .

Examine patient. If exam indicates that there may be difficulty with mask, LMA (emergen and surgical airway, discuss cy trach Unsuccesful Intubation after with surgeon before going to kit OR. Consider need forInduction included cardio-pulmonary bypass. on cart.) Note: If patient not Assist identified as difficult airway anesthesi until the day of surgery, then a in OR consult difficult airway team, during surgeon and scheduler prior induction. to proceeding.

INDUCTION

Anesthesia Induction General Guidelines: Identify Plans A, B, C prior to induction Preoxygenate patient prior to intubation attempts Maintain oxygenation during fiberoptic intubation attempts Maintain spontaneous ventilation until airway secured and during case unless surgical need for paralysis Limit direct laryngoscopy attempts toIf Anesthesia identifies two by attending, maximum of two by trainees (only if Unanticipated patient as patient oxygenated and ventilated) Difficult Intubation: RN to call Anesthesia Scheduler for help (#19705 or #19706) RN to call Anesthesia Tech (#5-0034) for difficult Airway cart If unstable, RN to call #211 STAT PEDS ANESTHESIA TO LOCATION Mask Ventilation Inadequate: Treat laryngospasm if indicated Attempt to ventilate via LMA

Succesful Intubation: Confirm with ETCO2 and BBS Check ETT depth Proceed to postinduction guidelines Mask Ventilation Adequate:

Alternative approaches to intubation (eg. Different blades, bougie, FOI via nares or LMA, video laryngoscope, blind intubation with intubating LMA, retrograde Failed Intubation/Successful Ventilation: intubation, lighted stylet) Consider proceeding with LMA or mask depending on urgency of case. (Not Recommended if: ENT case with potential for blood in oropharynx, large fluid shifts expected with possibility of airway edema, ENT/Anesthesia back-up unavailable.) If proceeding with case: discuss plan for lost airway during case, anesthesia should be single-coverage If cancelling/rescheduling, what will be done differently in the future? 8

Failed Intubation/Failed Ventilation: Call ENT Consider awakening patient Emergency Invasive Airway access if persistent hypoxia (Needle cricothyroidotomy not recommended under 5 yrs)

Guidelines for Securing the ETT: POSTINDUCTION Tape and suture ETT in ENT cases (preferably sutured through periosteum, wired to teeth, or circummandibular suture) Ensure no tension on circuit (if head to be moved side to side during caseperform maneuver with surgeon to test set-up) Consider turning table only 90, or not all Time Out: Anesthesia to identify patient as difficult airway or not Identify first step in the event of intraoperative lost airway RN to identify ENT contact to be called in case of intraoperative lost airway EMERGEN CE/TRANS PORT Team to discuss disposition IF Extubation Planned: Awake extubation Consider extubation over airway conduit (eg. Cook exchange catheter) IF ICU Transport: IF PACU Disposition: Circulating RN to identify patient as difficult airway patient when PACU called. PACU to alert RT to be present for PACU sign-out and available to monitor patient in PACU. Anesthesia: sign out to ICU fellow or attending 45 minutes prior to transport Verify secure ETT prior to transport Emergency drugs and sedation available for transport Supra-glottic airway device and portable suction available Plan for inadvertent extubation ICU team to order sedation for patient to be available for patient on arrival to ICU RN to sign-out to ICU RN and post Critical Airway sign on bed

Anesthesia to: Discuss Airway management with Parent/Guardian and provide documentation of difficult airway status for their records.

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