“Sedation versus General Anesthesia For Tracheal Intubation In Children With Difficult Airways

Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of our study is to compare the first attempt success rate of tracheal intubation during sedated tracheal intubation vs. tracheal intubation under general anesthesia (GA). We hypothesized that sedated intubation would be associated with a lower first attempt success rate and more complications than general anesthesia.

We used data from an international observational registry, Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. We compared the use of sedation versus general anesthesia for tracheal intubation. Our primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and non-severe and severe complications. We used propensity score matching with a matching ratio up to 1:15 to reduce bias due to measured confounders.

Between 2017 and 2020, 34 hospitals submitted 1839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation and 1764 patients received GA. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the GA group. The rate of first-attempt success of tracheal intubation was 28/58 (48.3%) in the sedation group and 250/522 (47.9%) in the GA-group (OR 1.06, 95% CI 0.60 – 1.87; p=0.846); The median number of intubations attempts was 2 [IQR 1, 3] in the sedation group and 2 [IQR 1, 2] in the GA group. The GA group had 6/522 (1.1%) intubation failures versus 0/58 in the sedation group. However, Sixteen of fifty-eight (27.6%) sedation cases had to be converted to GA for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low.

Sedation and GA had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to GA to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low.