The airway specialist could be either a registrar or consultant anaesthetist or emergency medicine specialist. The on-call anaesthetic consultant could seek the help of another consultant anaesthetist with paediatric expertise or trauma consultant/PICU consultant in Cambridge University Hospitals through NCS if required.

Pre-anaesthetic induction checklist

Is pre-oxygenation in progress?

Monitoring

What is the heart rate? Can it be improved?
What is the blood pressure? Can it be improved?
What are the oxygen saturations? Can they be improved?

Equipment

Which laryngoscope blade size and type will be used?
Which tracheal tube size and lengths will be used?
Is bougie size appropriate for tube chosen?
Are all equipment items checked?
Is ETCO2 connected?
Is suction turned on and pre-positioned?
Are the BVM and ventilator ready for use?
Is there any additional rescue airway equipment needed?
Is there an adequate sized orogastric tube?

Drugs

What induction agent?
Is dose appropriate for age, weight and BP?
What muscle relaxant?
Are any other emergency drugs needed?
Are there two points of adequate vascular access?
Are fluids connected and running easily?

Staff

Who is giving the drugs? Have they been briefed?
Who is the operator? Has their position been optimised?
Who is providing cricoid pressure? Have they been briefed?
Who is the assistant? Is the team and equipment in the right position?
Who is providing cervical stabilisation? Is the collar open?

Checks complete
Note time and mark induction on the monitor. Give induction drugs.
Post intubation, maintain sedation and muscle relaxation with drug infusions (see drug monograph in additional information for doses).

→ Section 11.d

Transfer infusions: Propofol

→ Section 11.d

Transfer infusions: fentanyl

Suggested protocol for induction of anaesthesia

Induction agents

It is recommended that the airway specialist should use induction drugs that they are familiar with and alter the dosage according to clinical circumstances. It is also suggested opioids should be used (even in head injured patients) as analgesic and also as an adjuvant to induction drugs (to reduce the dose of anaesthetic drug needed for induction of general anaesthesia). Fentanyl at a dose of 0.5 to 2mcg/kg is a popular choice of opioid.

In relatively normovolemic children

• Propofol 2–4mg/kg
• Ketamine 2–3mg/kg (good evidence suggesting no increase in ICP with ketamine and hence its use in trauma patients including children with head injuries). If unfamiliar with use of ketamine for induction of general anaesthesia, please use the induction drug familiar to you.

In hypovolemic children

• Ketamine 1–2mg/kg
• Etomidate 0.2–0.3mg/kg
• Propofol 1–2mg/kg (slow titrated injection)

Muscle relaxants

• Suxamethonium 2mg/kg (avoid suxamethonium in children with chronic neuromuscular conditions, renal failure, burns more than 12 hours old, and high spinal cord injuries more than 12 hours old).
• Rocuronium 1mg/kg (caution to be exercised if difficult airway or difficult intubation is anticipated, and sugammadex not available).

Maintenance of anaesthesia

• Anaesthesia maintained with midazolam infusion at 50–300 mcg/kg/hr and morphine 20–50 mcg/kg/hr. (If more familiar, propofol infusion can be used in haemodynamically stable children for transport purposes, for no more than 12 hours.)
• Bolus muscle relaxant with Atracurium 0.5mg/kg or Rocuronium 1mg/kg.

Difficult airway algorithm

The following three guidelines relate to the management of the unanticipated difficult airway in children aged 1 to 8 years.

They are:

• difficult mask ventilation during routine induction of anaesthesia in a child aged 1 to 8 years
• unanticipated difficult tracheal intubation during routine induction of anaesthesia in a child aged 1 to 8 years
• cannot intubate and cannot ventilate (CICV) in a paralysed anaesthetised child aged 1 to 8 years

Paediatric patients are looked after in many hospitals and specialist paediatric services are neither necessary nor appropriate in all settings. The target audience for these guidelines is for the non-specialist anaesthetist who wishes to learn or maintain paediatric airway skills, rehearse unexpected difficult airway scenarios and teach good practice.

These guidelines are clinical, but are backed by a robust process. A formal paper giving all the background data used to develop these guidelines will be published in the near future.

Internationally it was clear that most units are using airway management guidelines for children which have been expanded from adult practice. We have therefore specifically developed these guidelines following an exhaustive process which involved a Delphi analysis (which ensured careful reflection of each step of the pathway, and a grading of how confident an expert group was in endorsing each step), and an extensive literature review. Following this we had further external reviews, and placed the guideline on the APA website requesting comments; all views were considered. There is very little grade 1 (randomised control trial) evidence to support good practice in the management of the difficult paediatric airway, and guidance must therefore be essentially a clinical issue.

The Guidelines Group, supported by the Association of Paediatric Anaesthetists, the Difficult Airway Society and liaising with the RCoA, have taken a careful and thorough approach to review current practice. We hope these guidelines will be used widely, and would encourage feedback. We trust that, long term, they will be of use to all anaesthetists who manage children in day-to-day clinical practice, and those who teach safe airway techniques.