AI-assisted Tracheal Intubation in Children

Eligible patients will be prepared for intubation according to the local Standard Operating Procedures (SOPs) of the anaesthesia departments. Mandatory monitoring: saturation of peripheral oxygen (SpO₂), heart rate (HR), non-invasive blood pressure (NIBP), end-tidal carbon dioxide (EtCO₂).

The larynGuide™ software system (consisting of 2 displays, one regular C-MAC video laryngoscope monitor (KARL STORZ, Tuttlingen, Germany) which will be used by the board-certified anaesthesiologist for intubation and the other one for the study team displaying the software which is not to be seen from the anaesthetist perspective) is being taken to the induction room making sure that display is not to be seen from the anaesthesiologist point of view.

Induction of anaesthesia: If feasible, all children included in this protocol will be pre oxygenated before induction of anaesthesia for one minute through face-mask with Fraction of inspired oxygen (FiO₂) 1.0 and flow rates of 6-10L/min. The induction of anaesthesia for tracheal intubation will be performed using a combination of sedative/hypnotic drugs, opioids and non-depolarizing muscle relaxant. The following medications will be mandatory as per protocol:

• One or more of the following hypnotic agents (Thiopentone 4-7 mg/kg, Ketamine 0.5-2 mg/kg, Propofol 1-4 mg/kg, Midazolam 0.5-1 mg/kg, Sevoflurane up to 8%).
• An opioid drug and anticholinergic can be chosen and administered at the discretion of the anaesthetist in charge.
• A neuromuscular blocking agent (NMBA): Rocuronium 0.5-1 mg/kg, Cis Atracurium 0.2-0.5 mg/kg, Atracurium 0,5 mg/kg, Vecuronium 0.1 mg/kg, Mivacurium 0.2 - 0.3 mg/kg or Succinylcholine 2 mg/kg.

Before intubation: After induction of anaesthesia and the administration of a NMBA, bag-mask ventilation with FiO₂ 1.0 (flow rates of 6-10 L/min) will be performed for 60 seconds until apnea sets in. Thereafter bag-mask ventilation will be stopped and apnoeic oxygenation (1l/kgBW) will be started. Video laryngoscopy will be performed with a C-MAC video laryngoscope and the patient's trachea will be intubated. Once the intubation attempt is completed, the software displays a green light for the correct tube position or the words "Bad intubation" on the monitor (which is only seen by the study personnel). The anaesthesiologist in charge (board certified) performs checks to assess the correctness of the tracheal tube position by visual check and by attaching the patient to the ventilator and measuring the endtidal carbon dioxide (CO₂) (Gold standard to rule out oesophageal intubation in anaesthesia). After the board-certified anaesthesiologist communicated to have completed the intubation attempt, the research staff will look if the software displays a green light or the words "Bad intubation" on the monitor.