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The VISI RCT – VL or DL for Infant Intubation?

January 20, 2021

Written by Aaron Lacy

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In this study, infants undergoing intubation with standard geometry video laryngoscopy (VL) had a higher first pass success rate and fewer severe complications when compared to infants intubated with direct laryngoscopy (DL).

Why does this matter?
There is a strong argument for VL as standard of care, including in pediatric patients – but what about for infants? For non-pediatric anesthesiologists, perhaps no other patient would make you sweat more pre-intubation; so, whatever you can do to optimize your success rate should be done.

I can see clearly now, the VL is here
564 infants across multiple countries undergoing endotracheal intubation (ETI) in the operating room were randomly assigned to standard geometry (as opposed to hyperangulated) video laryngoscopy or direct laryngoscopy. 93% of infants in the VL group had first pass success during ETI, versus 88% in the DL group (absolute risk difference 5.5% [95% CI 0.7 – 10.3, p = 0.024]). Severe complications (moderate and severe hypoxemia, esophageal intubation, pharyngeal bleeding) occurred in 2% of infants in the VL group versus 5% in the DL group (-3.7% [-6.5 to –0.9%, p = 0.0087]). There was 1 esophageal intubation in the VL group versus 7 in the DL group. The study was funded by Karl Storz corporation.

While complications for both groups were low, extrapolated to a scale of total infant intubations worldwide, VL would seem to have a substantial impact in terms of reducing second intubation attempts and severe complications. These were controlled, elective intubations in an operating room. In an urgent ETI for an emergency department patient, if available, I would reach for VL.

First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet. 2020 Dec 12;396(10266):1905-1913. doi: 10.1016/S0140-6736(20)32532-0.

What are your thoughts?