This page is part of the Safetots Crisis SOPs, a framework for prevention and treatment of the most relevant crisis situations in pediatric anaesthesia.
Can’t oxygenate-ventilate situations in children are common and are usually due to functional and/or anatomical airway obstructions. Early recognition and treatment with appropriate skills, equipment and drugs can overcome these situations in otherwise healthy children.
- most common complication with potential serious morbidity and mortality
- most frequent complication in otherwise healthy children
- often associated with lack of skills, knowledge, education, training, experience and the use of age inappropriate equipment
- infants and toddlers at particular risk
- high risk surgeries (ENT)
Identify children at risk
- the child with acute airway infection, bronchial hyperactivity, asthma, allergic predisposition
- premature, neonates, infants and toddlers
- history, signs and symptoms predictive for difficult airway
- obstructive sleep apnea syndrome (OSAS)
- acquired and congenital airway abnormalities and diseases
Strict transfer policy regarding children at risk
Seek experienced consultation and help early
Infrastructure and competence
Anesthesia for children should be undertaken or supervised by anesthetists who have undergone appropriate education, training and experience
- suitable anesthesia environment
- appropriate patient positioning
- basic age specific airway equipment
- appropriate depth of anesthesia
- immediate access to emergency drugs (prepared)
- pre-oxygenation as appropriate and accepted by patient
- recognize and treat anatomical/mechanical airway obstruction
- call for help early
- recognize and treat functional airway obstruction
- exclude and treat foreign body airway obstruction
- perform endotracheal intubation / insert laryngeal mask airway
- (Can’t oxygenate, can’t intubate (COCI) – invasive oxygenation/ ventilation via front of neck airway)
- debriefing is essential (patient, parent, staff)
- ensure good documentation (patient records, alert card, bracelet)
- Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, von Ungern-Sternberg BS. A framework for the management of the pediatric airway. Paediatr Anaesth. 2019 Oct;29(10):985-992
- Paterson N, Waterhouse P. Risk in pediatric anesthesia. Paediatr Anaesth 2011; 21: 848-57.
- Mir Ghassemi A, Neira V, Ufholz LA, Barrowman N, Mulla J, Bradbury CL, Bould MD. Systematic review and meta-analysis of acute severe complications of pediatric anesthesia. Paediatr Anaesth 2015; 25: 1093-1002.
- Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth 2010; 20: 454-64.
- Weiss M, Schmidt J, Eich Ch et al. Handlungsempfehlung zur Prävention und Behandlung des unerwartet schwierigen Atemwegs in der Kinderanästhesie. Anästh Intensivmed 2011; 52: S54-S63.
- Engelhardt T, Machotta A, Weiss M. Management strategies for the difficult paediatric airway. Trends in Anaesthesia and Critical Care 2013; 3: 183-7.
- BlackAE, Flynn PE, Smith HL, ThomasML, WilkinsonKA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015; 25: 346-62.
- Weiss M, Engelhardt Cannot ventilate–paralyze! Paediatr Anaesth. 2012; 22: 1147-9.
- Both CP, Diem B, Alonso E, Kemper M, Weiss M, Schmidt AR, Deisenberg M, Thomas J. Rabbit training model for establishing an emergency front of neck airway in children. Br J Anaesth. 2021 Apr;126(4):896-902.
- Hsu G, von Ungern-Sternberg BS, Engelhardt T. Pediatric airway management. Curr Opin Anaesthesiol. 2021 Jun 1;34(3):276-283
- Thomas J, Alonso E, Wendel Garcia PD, Diem B, Kemper M, Weiss M, Both CP. Cuffed versus uncuffed tracheal tubes in a rabbit training model for establishing an emergency front-of-neck airway in infants: a prospective trial. Br J Anaesth. 2022 Feb;128(2):382-390.
See all Cs:
- Can´t Oxygenate – Can´t Ventilate
- Can´t Intubate
- Can Intubate – Can’t Oxygenate
- Can´t Cannulate – Failed Venous Access
- Major Hemorrhage
- Perioperative Pulmonary Aspiration
- Tonsillar Bleeding
- Local Anesthetic Systemic Toxicity – LAST
- Malignant Hyperthermia Crisis – MH
Learn about …
- Rights of the child (10Rs)
- Personal and institutional competence (5Ws)
- Quality and equilibrium (10Ns)
- Crisis situations (10Cs)
- Quality Improvement
- Parental discussion