When can we give general anesthesia to an infant with anticipated difficult airway management caused by facial vascular malformation?

When facial vascular malformations are compromised with anticipated difficult airway management, it becomes more difficult to determine appropriate timing of surgery. Few case reports exist that describe airway management for surgical resection of facial hemangioma in children [2, 3]. Although they can have rapid progression and spontaneous involution in 90% of cases, vascular malformation usually shows slow progression, without spontaneous regression [4]. They also require different therapeutic management, depending on its localization; in this case, as the vascular malformation in his upper lip started bleeding while undressing, the first surgery was scheduled for resection of the vascular malformation in his upper lip. Although this surgery was safely performed as planned, the risk of massive nose bleeding eventually became lethal. It is difficult to ascertain the exact optimal time, since other factors like vascular malformation can influence the airway, risk of bleeding, heart load due to hypervolemia, and parental mental distress.

In the presented case, we decided that appropriate timing for general anesthesia in an infant with anticipated difficult airway management was when the infant grew to 10 kg and could be treated with the cricothyroid membrane puncture kit. Although it is difficult to evaluate the safety of cricothyrotomy devices for infants, Metterlein et al. reported successful placement of QuickTrach Baby™ (VBM Medizintechnik GmbH, Sulz am Neckar, Germany) in adult rabbits [4]. However, Stacey et al. reported that cannula tracheostomy in a model comparable to an infant’s airway was still difficult and not performed without complication [5]. Because little evidence exists to guide the management of the “can’t intubate, can’t oxygenate” scenario in pediatric anesthesia [1], weight may not predict appropriate timing for general anesthesia in an infant.

In this case, we did not use muscle relaxants during endotracheal intubation, although they are recommended in the management of unexpected difficult pediatric airways [6]. As stated, in this kind of pediatric airway management, this does not relate to failure to intubate, but failure to recognize and overcome functional airway problems; this is due to insufficient depth of anesthesia or muscle paralysis, leading to morbidity and mortality. In addition, sugammadex can immediately reverse the neuromuscular block caused by rocuronium or vecuronium [7]. Muscle paralysis would similarly help reduce the risk of accidental bleeding from the tumor, particularly at the upper lip. However, we did not use muscle relaxants, as we had little experience in the management of difficult infant airways. Therefore, in this case, we preferred to maintain spontaneous breathing, which is what we usually do when managing anticipated difficult airways in adults.

It would have been preferable if this surgery was performed at a children’s hospital with pediatric anesthesiologists, although we could not find any appropriate surgeons for the possibility of surgical removal, along with an acceptable volume of intraoperative bleeding. As a secondary measure, we encouraged the parents to talk with several anesthesiologists at children’s hospitals before treatment at our hospital. This helped the parents understand the infant’s pathology and the inherent risks associated with airway management; this understanding also alleviated their level of anxiety.

We did not decide whether to extubate in advance of surgery, so an endotracheal tube was successfully removed afterwards, with the infant immediately requiring sedative drugs. Because the vascular malformation was removed as planned, we interpreted it to mean that there was no further risk of airway obstruction by his vascular malformation. When resection of facial vascular malformation is planned, children are usually not cooperative enough to evaluate the degree of invasion of the vascular malformation. However, it becomes clear after induction of general anesthesia, whether the lesion can be securely and surgically removed then. It may be a safe strategy to use general anesthesia and not extubate all patients in the operating room, although prolonging unnecessary intubation can cause other problems in the ICU. The decision to extubate requires close communication with the surgeons, in accordance with the progress of the surgical procedure.