June 1998

A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis.
Cook-Sather SD, Tulloch HV, Cnaan A, et al. Anesth Analg. 1998;86:945-51.
[ see abstract below ]

Cook-Sather et al have prospectively compared two approaches to tracheal intubation in infants with pyloric stenosis. Traditional teaching when I trained at that very same institution was that awake intubation would reduce the potential for pulmonary aspiration of gastric contents. As the years have gone by and having observed many residents and fellows struggle with the "awake" intubation of a healthy robust infant, a number of surgeons commented "why not use succinylcholine, as one would in other "full stomach" patients? All patients in this current study had their stomach evacuated through suctioning while in the supine, right, and left lateral position, which in a previous study by the same authors demonstrated virtual emptying of the stomach (Cook-Sather SD, Tulloch HV, Liacouras CA, Schreiner MS. Gastric fluid volume in infants for pyloromyotomy. Can J Anaesth 1997;44:278-283). This previous paper provides a degree of comfort regarding the present study because, in fact, the stomachs were in all likelihood already empty.

This current study has demonstrated that, in the authors' hands at a teaching institution, time to tracheal intubation was shorter in those patients who received a muscle relaxant, successful intubation on first attempt was greater with relaxants, and there was no difference in the incidence of desaturation. (Interestingly the one patient who vomited on induction was the only infant whose stomach was not evacuated prior to induction.) There was also no difference in the incidence of bradycardia between techniques, and this may have been related to the routine administration of atropine prior to attempts at laryngoscopy or prior to induction. Importantly, however, the authors recommend this technique (rapid sequence or modified rapid sequence) only after assurance that the airway anatomy is normal and when experienced pediatric anesthesiologists are immediately available. I would second this caveat because once a relaxant is administered the bridges are burned.

The following conclusions can be drawn from this paper: preoxygenation is good, prior administration of atropine is good, prior evacuation of the stomach in three positions is good, and "awake" intubation may not offer advantage over paralyzed intubation in the hands of able practitioners, including an experienced pediatric anesthesiologists. It should be noted, however, that there was the potential for significant bias because this was a non-randomized study. In my current practice with residents and fellows, I have abandoned "awake" intubation of infants for either a rapid-sequence with succinylcholine or a modified rapid-sequence with rocuronium and cricoid pressure with gentle ventilation. In the hands of an experienced endoscopist, I doubt that there is much difference. Perhaps that would be a good follow-up study: compare intubations in awake infants performed by attendings and resident/fellows (assuming that their vision is better than mine).

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ABSTRACT