Paediatric anaesthesia03 / 17
Pierre Robin infant for hernia repair10-week-old boy, term-born, 4.2 kg, with Pierre Robin sequence
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Know this first
- Pierre Robin: small jaw, tongue falling back and obstruction; prone or lateral positioning helps.
- Mask ventilation may be nearly impossible; keep him breathing until the airway is secure.
- Direct laryngoscopy usually fails; set up videolaryngoscope and fibrescope from the start.
- Complications rise under 10 kg and after more than two intubation attempts.
- Under 12 years, needle cricothyroidotomy is preferred over a surgical one.
The patient
10-week-old boy, term-born, 4.2 kg, with Pierre Robin sequence, for elective right inguinal hernia repair.
Small jaw and cleft palate; obstructs lying on his back, settles prone; slow feeding. Echo normal.
No regular drugs.
Vitals: HR 145, BP 78/44, SpO2 96% on air prone, RR 44.
The examiner asks
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Consider
What are your concerns?
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- A 10-week-old with Pierre Robin sequence, obstructing on his back, for elective hernia repair. Patient
- As an infant he breathes through his nose and desaturates fast; small swelling narrows his airway badly.
- His small jaw pushes the tongue back: mask ventilation and laryngoscopy may both fail. Airway
- Under 10 kg his airway complications climb, especially beyond two attempts.
- Short groin surgery: a caudal block can cut the anaesthetic and opioid he needs. Surgery
Prepare
How will you prepare?
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- Airway plan agreed with the team: first plan, rescue, and ENT scrubbed for an emergency airway. Airway
- Videolaryngoscope with an infant blade, a fibrescope and an infant intubating SGA set up beforehand.
- Nasopharyngeal airway ready; lateral or prone position relieves his obstruction.
- Oxygen by nasal cannula during and between attempts; atropine and propofol drawn up.
- Caudal bupivacaine 0.25%, 1 mL/kg for lumbar spread, once he's asleep. Surgery
Plan
How do you induce him and secure his airway?
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- Gas induction in sevoflurane and oxygen, keeping him breathing on his own. Airway
- Lateral position, jaw thrust or a nasal airway to bring his tongue forward.
- No relaxant until I've shown I can ventilate him.
- First look with the videolaryngoscope; direct laryngoscopy usually fails in him.
- Fallback: an SGA, then a fibrescope through it into his trachea.
- Extubated fully awake, then monitored overnight for obstruction. After surgery
Crisis
Two videolaryngoscope attempts fail; SpO2 is 94% with mask CPAP. What now?
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- Difficult airway algorithm: failed intubation, still oxygenating; senior help now. (Crisis)
- No more laryngoscopy; past two attempts his complications rise.
- Keep him breathing on 100% oxygen with jaw thrust and gentle CPAP.
- Infant SGA in; if it ventilates well, fibreoptic intubation through it.
- If that fails too, I don't persist: wake him, and the hernia waits.
Crisis
Through the SGA, ventilation suddenly fails: SpO2 70%, HR 90. What do you do?
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- Can't oxygenate: say it out loud; ENT to his neck now. (Crisis)
- One quick fix: reseat or resize the SGA with jaw thrust, turning him lateral.
- Still not oxygenating: no delay to front-of-neck access.
- Under 12, needle cricothyroidotomy over a surgical one, or ENT rigid bronchoscopy or tracheostomy.
- Rate below 60 and poorly perfused even with oxygenation: chest compressions.
Fatal mistakes
- A relaxant before ventilation is proven.
- Repeated laryngoscopy as his saturation falls.
- No ENT surgeon or front-of-neck plan before induction.
- Deep extubation, or sending him home the same day.
Checked against: Stoelting 8e · Barash 9e · Miller 10e
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