Traditional Poster Round
Background: : Unanticipated difficult airways leading to “cannot ventilate, cannot oxygenate” situations are very uncommon in children but are associated with poor outcome. Appropriate pediatric airway expertise along with a predetermined plan of action are paramount. There is no evidence on how to train for emergency front of neck access (eFONA) in children younger than 8 years of age (1-3).
Research Question: : We propose a rapid sequence tracheotomy (RST), which shall be researched using rabbit cadavers. The aim of this study is to provide pediatric airway practitioners with a realistic training model to practice eFONA.We seek to investigate how participants can acquire this skill set with increasing practice analyzing the learning curves and recording concurring injuries.
Methodology: : At the Bern University Hospital 10 pediatric anesthesiologists and 10 pediatric surgeons without prior eFONA-experience, each performed 10 rapid sequence tracheotomies (RST) on rabbit cadavers, after watching an instructional video. The goal was to perform RST in under 60 sec. Performance time, learning curve and rate of severe injury (damage to cricoid and thyroid) was recorded.
RST (4) consists of four steps:
1st: Orientational palpation and vertical midline skin incision (scalpel curved blade #10), followed by
2nd: Strap muscles separation (2 Backhaus clamps) and exposure of the trachea and cricoid by anterior luxation of the trachea with a 3rd clamp.
3rd: Vertical puncture with tip scissors and incision of no more than 2 rings.
4th: Endotracheal insertion of proper sized tube and lungs inflation.
Results: : Preliminary results indicate a 1st attempt time of 85 ± 33 sec for anesthesiologists and 99 ± 33 sec for surgeons, with a rate of severe injuries of 60%. Upon the 10th attempt anesthesiologists / surgeons were able to perform RST in 55 ± 12 / 46 ± 13 sec, while reducing severe injuries to 5%. Only 1 consultant (5%) was unable to perform RST in <60 secs.
Over all 10 attempts paratracheal insertion and severe injury occurred at a rate of 4.5% and 13.0% respectively. Improvement in performance time was significant for both groups between the 1st and the 10th attempt (p<0.001). There were no differences in performance time between the two groups.
Discussion/Conclusions: : Steady skill improvement was observed irrespective of consultant specialty. Despite an overall success rate of 97%, the rate of severe injuries and paratracheal tube placement remained high. Injuries were extremely common upon initial attempt and then decreased sharply but remained steady throughout the subsequent attempts. This suggests that recurring training is essential to lower the rate of tube misplacement and injury. Our data are insufficient to determine how many repetitions are needed to acquire a sufficient expertise.