Because there are inherent risks in inducing anesthesia and securing the airway in this neonate, one would prepare for a combined supraglottic airway-fiberoptic intubation. The infant bronchoscope is so small in diameter that it does not accommodate a suction port, and visualization can be impaired by excessive secretions. An antisialagogue should be given at least 15 to 20 minutes before beginning the fiberoptic intubation to facilitate recognition of the anatomy. Glycopyrrolate (0.01 mg/kg intravenously [IV] or intramuscularly [IM]) will limit secretions without causing the excessive tachycardia that can occur with atropine. In this neonate with cardiac compromise, unnecessary stress on the heart should be avoided. In addition to a fiberoptic bronchoscope and appropriate laryngeal mask airway (LMA) being available, a videolaryngoscope and equipment trays for an emergency cricothyrotomy should also be ready. Having a pediatric otolaryngologist present for induction of anesthesia as well as a rigid infant bronchoscope with video imaging capability should also be considered. The rigid bronchoscope cannot only facilitate visualization of the laryngeal inlet, but it can also provide a route to temporarily ventilate the patient and hold the endotracheal tube as an introducing stylet to facilitate intubation. Passive oxygenation should also be utilized during intubation attempts to prolong the time to desaturation.

References

• Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022;136:31-81.
• Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth. 2020;30:269-279.