Clinical outcome of perioperative airway and ventilatory management in children undergoing craniofacial surgery.

Data on the management of perioperative airway and ventilatory support in children undergoing craniofacial surgery are limited. The purpose of this study was to review the authors' experience with airway management and ventilatory support during the perioperative period in children undergoing craniofacial surgery. Ninety-five consecutive children underwent 99 craniofacial procedures from July 1, 1999, through June 30, 2002. Direct laryngoscopy was successfully used to establish an airway in 86 (86.8%) cases, whereas 13 (13.1%) cases required the use of fiberoptic bronchoscopy to establish an airway before surgery. The oral route was used in 82 (83%) cases, and the nasal route was used in 17 (17%) cases. Length of anesthesia was 330 +/- 160 minutes, and the actual surgical time was 246 +/- 151 minutes. The volume of crystalloids infused during surgery was 87 +/- 78 mL/kg body weight (BW), and the volume of packed red blood cells infused during surgery was 10 +/- 14 mL/kg BW (range, 0-60 mL/kg BW). Tracheal extubation was successfully accomplished in the postanesthesia recovery unit (PACU) in 57 (58%) patients, whereas 42 patients were admitted to the pediatric intensive care unit (PICU) and received mechanical ventilation for 10 +/- 9 hours (range, 1-60 hours). Of these, 37 (37%) were extubated in the PICU, whereas 5 patients were extubated in the operating room with the craniofacial surgeon in attendance in the event an emergency tracheostomy was needed. However, none of these patients required tracheostomy to maintain a secure airway. Three patients required reintubation after the first attempt at tracheal extubation in the PICU. All three of those patients subsequently were extubated without the need for tracheostomy. The length of tracheal intubation and mechanical ventilation was longer (24 +/- 13 hours versus 8.6 +/- 7 hours, P < 0.001) in patients who required bronchoscopic intubation than in those who were intubated using direct laryngoscopy. The length of hospital stay, although clinically relevant, did not reach statistical significance between the two groups (5 +/- 7 days versus 3.7 +/- 2.7 days, P = 0.5). A positive correlation was observed between the duration of tracheal intubation and mechanical ventilation and the following perioperative factors: anesthesia time (rho = 0.6, P < 0.01), surgical time (rho = 0.55, P < 0.01), volume of crystalloids (rho = 0.5, P < 0.01), and the volume of packed red blood cells infused (rho = 0.55, P < 0.01) during surgery. No episodes of cardiorespiratory arrest or death occurred in any of the patients. This study demonstrates that when performing complex craniofacial procedures in children, a thorough evaluation of the airway before surgery and continuous communication between specialists during the perioperative period is imperative for a successful outcome. Furthermore, most pediatric patients who require mechanical ventilation during the postoperative period do so for a short period of time following surgery.