Department of Anesthesia, Our Lady's Children's Hospital Crumlin, Dublin, Ireland.
Department of Anesthesia, Galway University Hospital, and National University of Ireland, Galway, Ireland.
Paediatr Anaesth. 2020 Jan;30(1):69-77. doi: 10.1111/pan.13773. Epub 2019 Dec 4.
Emergency front of neck access in a "can't intubate can't oxygenate" scenario in pediatrics is rare. Ideally airway rescue would involve the presence of an ear, nose, and throat surgeon. If unavailable however, responsibility lies with the anesthesiologist and accurate identification of anterior neck structures is essential for success.
We assessed anesthesiologists' accuracy in identification of the pediatric cricothyroid membrane by digital palpation in three predefined age groups (37 weeks to <1 year old, 1-8 years old, and 9-16 years old) and whether accuracy improved with repetition. We also investigated a novel hypothetical vertical skin incision strategy to successfully expose the cricothyroid membrane.
We asked anesthesiologists to identify the location of the cricothyroid membrane of anesthetized children in the extended neck position. Accuracy was defined as a mark made within the margins of the cricothyroid membrane using ultrasound as a reference standard. The position of the cricothyroid membrane relative to the neck midpoint, between the suprasternal notch and mentum, was defined for each child. Using this neck midpoint, we determined the hypothetical vertical skin incision lengths required to successfully expose the cricothyroid membrane ("midpoint incision").
Ninety-seven patients were included in this study. There were 14, 58, and 25 patients recruited across the three predefined groups. Accurate anesthesiologist identification of the location of the cricothyroid membrane occurred in 29.4%, 28.6%, and 38.2% of attempts, respectively. The majority of inaccurate assessments (64.1%) were below the cricothyroid membrane. There was no improvement in accuracy with repetition. Hypothetical "midpoint incision" lengths of 20, 30, and 35 mm were required.
Significant anesthesiologist inaccuracy exists in locating the cricothyroid membrane in children of all ages. This has implications for the technical approach to emergency front of neck access and how we teach the management of "can't intubate can't oxygenate" in pediatric practice.
在儿科中，“无法插管无法给氧”的紧急情况下，经颈前路进入气道的情况很少见。理想情况下，气道救援需要耳鼻喉科外科医生的参与。但是，如果无法获得这种支持，那么责任在于麻醉师，并且准确识别颈部前方结构对于成功至关重要。
我们通过数字触诊评估了麻醉师在三个预定义年龄组（37 周以下至 1 岁以下，1-8 岁和 9-16 岁）中识别小儿环状软骨膜的准确性，以及重复操作是否会提高准确性。我们还研究了一种新的假设垂直皮肤切口策略，以成功暴露环状软骨膜。
我们要求麻醉师在患儿颈部伸展的位置上识别麻醉患儿的环状软骨膜位置。准确性的定义是使用超声作为参考标准，在环状软骨膜的边缘内做标记。为每个孩子定义环状软骨膜相对于颈中点（胸骨上切迹和颏骨之间）的位置。使用该颈中点，我们确定了成功暴露环状软骨膜所需的假设垂直皮肤切口长度（“中点切口”）。
本研究共纳入 97 例患儿。在三个预定义的组中，分别有 14、58 和 25 名患儿入选。在尝试识别环状软骨膜位置时，麻醉师的准确识别率分别为 29.4%、28.6%和 38.2%。大多数不准确的评估（64.1%）都低于环状软骨膜。重复操作并没有提高准确性。假设的“中点切口”长度为 20、30 和 35mm。
在所有年龄段的儿童中，麻醉师在定位环状软骨膜时都存在明显的不准确。这对紧急经颈前路进入气道的技术方法以及我们在儿科实践中如何处理“无法插管无法给氧”的管理产生了影响。
