A full term 2 day-old boy has been persistently vomiting and has been in the neonatal intensive care unit since birth in a community hospital. After delivery, the baby was vigorous, and had APGAR scores of 9/9. The neonatologists order an abdominal x-ray which reveals multiple air-fluid levels indicative of small bowel obstruction. The surgeons are worried about intestinal perforation, and want to operate emergently. You are on call and immediately attend to the baby for assessment. You notice severe micrognathia, with indrawing of the chest, indicative of upper airway obstruction. The neonatologist also mentions that this child may have Pierre Robin syndrome.

Physical examination:

Vital signs: HR 166; RR 44; BP 70/30; SpO 93%. On 4 liters via nasal cannula; peripheral intravenous line in place

What would be the most appropriate next steps in managing this child’s airway for surgery?

a. Rapid sequence induction with propofol and succinylcholine followed by direct laryngoscopy with a bougie.

b. Rapid sequence induction with ketamine and rocuronium followed by intubation with a video laryngoscope.

c. “Awake” placement of a supraglottic device followed by flexible fiberoptic tracheal intubation.

d. Call ENT to perform a tracheostomy after inducing and maintaining general anesthesia with Sevoflurane via mask ventilation.

e. Administer 1mg/kg of intravenous ketamine, followed by a look with a video laryngoscope.

f. Initiate CPAP and transfer patient to a tertiary care pediatric center.