favorite T and A recipe?

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nap$ter

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tonsillectomy and adenoidectomy, that is.

this is a basic procedure, but turnover time and keeping surgeons, patients, nurses, and families happy and impressed with your smoothness is an art. i see a LOT of variability within my group. my recipe is still evolving - i still learn new tricks often and my routine is not set in stone.

here's my current recipe (i'd love to see some others' recipes and hear opinions...):

i pull all meds at the beginning of the day

1. minimize premed usage but give it if necessary (i have cartoons and video games on my phone)

2. mask induction (n2o, sevo straight to 8, get em deep during IV (usually by the circulator)

3. if kid acts nice during induction, no meds for intubation. cuffed oral rae. most kids just keep right on breathing...

4. sevo maintenance (decreasing setting during case; 8, 4, 3, 2...). n20 OFF - maintain spont ventilation throughout procedure. 0.3% fio2 (2L/min).

5. morphine 50-150ug/kg IV depending on the rr/mv

6. decadron 0.5mg/kg up to 8mg, zofran 0.1mg/kg

7. IV tylenol - 15mg/kg (i push this in)

7.5. IVF 10-20mL/kg - LR

8. volatile off (flows 2L/min) when surgeon gives 3 minute warning.

9. "awake" extubation - if airway/breathing is minimal trouble/risk factors during case, i extubate when kid wakes up or when etsevo is 0.3 - whichever comes first.

we have great pacu nurses and our surgeons are fast and dry.

if the kiddos have severe OSA (or morbid obesity) and/or periop agitation or h/o emergence delirium i sometimes substitute or replace morphine with dexmedetomidine 50-200ug/kg IV.

if kiddos have borderline URI's, asthma, or give me any trouble with induction, i may give some propofol with induction/intubation to minimize bronchospasm and i may extubate more on the awake side (or deep side sometimes).

this is my current recipe but i am flexible still and try to be open to trying new things...

what do you guys do?

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i can't wait til i know what all this means o_O
 
Mine is very similar but we no longer have ofirmev since it went from $10 to $36/bottle. I basically do the same thing you do, but I'll occasionally use IM demerol but I've been burned once with it. One attending likes clonidine but I think it tends to delay PACU d/c in outpatients.

Our main peds ENT is a private guy and he's very quick so I have to get there super early to have all my drugs/tubes etc ready to go because he can turn out 10 kids in a half day. It's a fun but busy room, I usually don't take a lunch or a break on those days.
 
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My approach is similar but with a few differences.
1) the same, no premeds unless absolutely necessary
2) same
3) I give some propofol and fentanyl here just before DL. I spray the cords with atomized Lido and then place the tube. Some kids breath right thru this process and some stop for few minutes. If they stopped breathing, they start once the surgeon gets going.
4) same
5) skip the MS ( I used to give this but my surgeon injects local at the end so it is unnecessary)
6) same basically
7) NO More IV tylenol same as Kaz
7.5) same
8) same
9) this is were I differ from you. I pull the tube deep on every kid I can unless they are a difficult airway. I especially do this on kids with URI sx's. I give about 10-20mcg/kg of propofol and pull it. This gives me time to get the pt to pacu and give report. By the time this is done the kids will open there eyes half the time. The other half are so comfy they will sleep until someone wakes them.
Severe OSA kids I wake up in the OR and make absolutely sure they are good to go. Severity is determined by the induction for me. If they were difficult to mask and they couldn't move air well even with chin lift then they are severe.

I never give dex because I don't like mixing it and all the extra stuff that goes along with it ( accounting for waste). Plus I find propofol to be the best if not equal for wake ups.
 
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Noyac,
What's your EtSevo at when you pull the tube? Just wondering how much gas you have on board.
I don't have hard and fast ET number since I have given some propofol. It can be anywhere from 1.0- 0.3.
 
How do you choose your analgesia? Why morphine instead of dilaudid? Why not some fentanyl? Why not ketorolac if there's no ofirmev, assuming it's not too oozy?
 
There have been a few deaths in kids that got Ketorolac for T&As. The last 3 places I've worked didn't use it.
Was it really related? Who knows. T&As are not benign operations. I think the mortality is 1:35k.
Sometimes it seems like we do 35k a year in my shop alone.
 
There have been a few deaths in kids that got Ketorolac for T&As. The last 3 places I've worked didn't use it.
Was it really related? Who knows. T&As are not benign operations. I think the mortality is 1:35k.
Sometimes it seems like we do 35k a year in my shop alone.
Caution is advised. Thank you

So what's your recipe for T&A's?
 
How do you choose your analgesia? Why morphine instead of dilaudid? Why not some fentanyl? Why not ketorolac if there's no ofirmev, assuming it's not too oozy?

lotsa factors play into the recipe:

where i work, nurses are not familiar with dilaudid dosing in peds (if they were i would prefer dilaudid, but the advantage of dilaudid is too slight to justify the large amount of work that would be necessary for a culture change). fentanyl works great, better if your surgeon is good with local. my surgeons are dry and fast, but not so great with local - so i choose morphine for now.

a lot of my partners use IM demerol - works fine but i prefer to just use the IV and i think there's slightly less histamine release/n/v with IV morphine (and definitely fewer injection site reactions/sore muscles).

ketorolac works great but surgeons and nurses are quick to blame it for any bleeding. ketorolac is likely nearly equianalgesic compared to apap if not superior. ketorolac almost certainly does not cause bleeding after T and A (the best evidence supports this), but anecdotes and small studies fuel surgeon/nurse dislike for a great drug.

when the cost of dexmedetomidine comes down and acceptance increases i plan to use this drug in place of opiates. works great the times i have done this for osa/fat kids.

agree with noy - it all works more or less - the recipes have a lot of subjectivity and bias mixed in with a bit of evidence based practice.

the trick is to look slick and be efficient while minimizing rare complications - if you're not vigilant you can get into a lot of trouble...
 
There have been a few deaths in kids that got Ketorolac for T&As. The last 3 places I've worked didn't use it.
Was it really related? Who knows. T&As are not benign operations. I think the mortality is 1:35k.
Sometimes it seems like we do 35k a year in my shop alone.
Tonsils have real risk, agreed.

I admit though, that I've mostly blown off surgeons who blame bleeding on ketorolac or fear it because a patient might bleed. I don't believe poor surgical hemostasis can be justly blamed on a single dose of an NSAID. And in otherwise healthy patients (tonsils and not), I will often give ketorolac with induction because NSAIDs work better when given ahead of the insult and if I'm giving a drug I want full mileage out of it.

Maybe I'm a cowboy and shouldn't do that? I never been burned by it but I'm interested in opinions. I'm here to evaluate and modify my practice if warranted ...



I have two basic recipes for the uncomplicated peds tonsil:

The academic tonsil where "done in 5 minutes" means 5-15 minutes of in and out of suspension while the attending/resident check for hemostasis, and the patient has to stay deep enough for the bovie until I'm sure they're done. And the not-academic tonsil where "done in 5 minutes" means "done in 5 minutes" ...

I usually give kids PO midazolam on the academic days because the case number is low, and throughput is slow, and PACU discharge times don't matter, and there's a long turnover time between cases anyway. Time not being a factor, I think giving most kids pre-meds is a better anesthetic. Usually no pre-med on the non-academic days, as it's logistically hard to give it early enough to matter and I want them out of PACU fast.

Mask induction, IV, 20 mL/kg LR through the case, 2 mg/kg propofol no relaxant for intubation with a regular tube (don't like the oral raes), 0.5 mcg/kg fentanyl, FiO2 down, 100 mcg/kg of ondansetron and dexamethasone, IV acetaminophen and ketorolac for everyone up front.

I extubate them all awake because I don't trust the PACU to let kids emerge in peace. If they emerge with some pain I'll give 0.05-0.1 mg/kg of morphine before leaving for the PACU.
 
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No OSA or significant obstruction on induction-
0.5 mg/kg midazolam premed (max 10, 20 for big autistic dudes with hx of problems with procedures)
mask induction sevo/nitrous/O2
1mg/kg propofol for Oral RAE tube
0.1 mg/kg zofran (max 4)
0.5mg/kg dexamethasone (max 10)
Morphine 0.07 mg/kg
20mg/kg LR
Get spont vent immediately with PS
Maintain on O2/air (max 30% O2)
Sevo for real asthmatics, Des for everyone else.
Keep gas as low as possible w/sevo, if getting light 10-20mg propofol.
At 5 min, gas off morphine 0.05mg/kg. unless retaining CO2, or slow RR.
At stomach suction (1 min warning), flows up to 10L/min.
They usually wake within 5 min.
Extubate awake.

OSA-
Substitute Fent 0.5 mcg/kg at beginning and follow resp rate and ET CO2 to titrate more. They usually get between 1 and 2 mcg/kg.

Some partners extubate deep if not OSA. I generally do not, and would never at the ASC.
Some add 0.5mg/kg of Dexmedetomidine slow push at cut, though not at the ASC as it is believed to slow discharge. We are fast and furious at the ASC. No trainees, healthy kids, no breaks, done by 2.
I used to use dilaudid, now morphine. I don't see a difference.
If the surgeons think toradol is a risk factor for bleeding, that's enough for me. And if my kids had a T&A, I'd ask for no toradol. Though I would substitute Tylenol, which is not our norm. Maybe PO 2 hours before surgery?

PostOp-
oxy solution 0.1mg/kg (1/2 for OSA)
Morphine 0.03mg/kg up to 4 doses.

Severe OSA gets a reservation in the PICU overnight.
 
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Tonsils have real risk, agreed.

I admit though, that I've mostly blown off surgeons who blame bleeding on ketorolac or fear it because a patient might bleed. I don't believe poor surgical hemostasis can be justly blamed on a single dose of an NSAID. And in otherwise healthy patients (tonsils and not), I will often give ketorolac with induction because NSAIDs work better when given ahead of the insult and if I'm giving a drug I want full mileage out of it.

Maybe I'm a cowboy and shouldn't do that? I never been burned by it but I'm interested in opinions. I'm here to evaluate and modify my practice if warranted ...



I have two basic recipes for the uncomplicated peds tonsil:

The academic tonsil where "done in 5 minutes" means 5-15 minutes of in and out of suspension while the attending/resident check for hemostasis, and the patient has to stay deep enough for the bovie until I'm sure they're done. And the not-academic tonsil where "done in 5 minutes" means "done in 5 minutes" ...

I usually give kids PO midazolam on the academic days because the case number is low, and throughput is slow, and PACU discharge times don't matter, and there's a long turnover time between cases anyway. Time not being a factor, I think giving most kids pre-meds is a better anesthetic. Usually no pre-med on the non-academic days, as it's logistically hard to give it early enough to matter and I want them out of PACU fast.

Mask induction, IV, 20 mL/kg LR through the case, 2 mg/kg propofol no relaxant for intubation with a regular tube (don't like the oral raes), 0.5 mcg/kg fentanyl, FiO2 down, 100 mcg/kg of ondansetron and dexamethasone, IV acetaminophen and ketorolac for everyone up front.

I extubate them all awake because I don't trust the PACU to let kids emerge in peace. If they emerge with some pain I'll give 0.05-0.1 mg/kg of morphine before leaving for the PACU.

totally agree that ketorolac does not cause post t and a bleeding (that is a surgical coagulopathy, not a medical coagulopathy issue).

however, despite my extremely pro-ketorolac stance i do not give it unless the surgeon is FOR it, and we have a good relationship.

the risk of getting hung out to dry is not worth the mild add'l analgesic benefit.

i don't keep secrets from surgeons. (not saying anyone here has suggested one should...)

5 min for wakeup is too long imho.
 
Anyone else do 0.5-1 mcg/kg bolus of precedex right after the tube is out? Keeps them nice and chill in PACU...just be sure to push some glyco with it.
 
I for one do believe that Toradol "can" increase the bleeding risk. But that doesn't stop me from giving it in certain kids with certain surgeons. I just don't give it all that often. I believe if you give it early then you are usually safe because when it impairs clotting it does it pretty damn early. If you give it early then the surgeon spends more time cauterizing little bleeders because they actually bleed, even if they don't know you gave it. Later in the day, the issue may be minimal.

IlDestriero, i have a couple questions.
1) why never extubate deep at an ASC? This is the place for it. If your nurses are not confortable with it then break them in easy. Bring them one really straight forward pt one day. Then two the next time around. Before you know it they are asking you to bring them all out deep. The kids are awake before you are back in the OR, even if your ASC has 5-10 turnovers.
2) what's your PS settings for these little kids when you get them breathing spontaneously? I don't have this option at my ASC but curious?

One thing with MS vs Fentanyl for these cases. If you give fentanyl up front they will be apneic for longer so be cautious. Usually the stimulation will get them breathing. If you give MS then they will be less alert in recovery. Sometimes I like this, especially when they were worked up pre-op. But I "never" give pre-op versed in these kids or any kids. It confuses them too much post-op and they can be inconsolable. But some of my partners do and I watch their cases bottleneck in pacu because of it. I hate PO versed for these cases. If it's a difficult downs or CP then maybe ketamine. Maybe. Rarely.
 
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totally agree that ketorolac does not cause post t and a bleeding (that is a surgical coagulopathy, not a medical coagulopathy issue).

however, despite my extremely pro-ketorolac stance i do not give it unless the surgeon is FOR it, and we have a good relationship.

the risk of getting hung out to dry is not worth the mild add'l analgesic benefit.

i don't keep secrets from surgeons. (not saying anyone here has suggested one should...)

I don't lie to them. I just don't involve them in decisions I don't think they need to be a part of.

They don't ask me for permission to use 4-0 vs 3-0 sutures. I'm not going to ask permission to use certain drugs. There's only one board certified anesthesiologist in the room. If they ask for something specific - a higher dose of dexamethasone, or an antibiotic redose, I'll accommodate the request if it's reasonable. If they say "no Toradol" before I give it, I won't give it. I'm not looking to pick fights or create problems. Depending on my mood, I might try talking to them about what a great drug it is and how misplaced their Toradol-related bleeding concerns are.

It's not always easy. I had one surgeon lean over and say "you can give Toradol" toward the end of a lap chole a few weeks ago. I said "OK" but didn't move, and she followed up by asking if I already gave it, I said yes, and she got upset and began lecturing me about how it's her decision. I don't think very highly of her, but that's neither here nor there.


5 min for wakeup is too long imho.

It's all relative. You work with fast and consistent surgeons, it's easy to wake patients exactly when you want to.

They tack on an extra hour or 4, and vary closing time by 10-20 minutes patient to patient ... I like a lot of things about being back at an academic hospital, but man, perfectly timed wakeups are exponentially harder.
 
I'm not sure how to wake up a patient in less than 5 minutes when immediately before walking away from the table the kid is still in suspension and they are looking for oozing and burning away with the suction bovie. None of them use local and I don't want them bucking while suspended.
I don't extubate deep in the ASC because I am in the room with the next patient in 10 min. I don't want to have T&A patients in the PACU with nobody to back up a laryngospasm etc. I worry that the airway surgery and potential oozing increases their risk. I extubate pretty much everyone else deep there. If something happens at the big house, I'll probably be available to go to the PACU as well as 20 other anesthesiologists, and an army of support staff. No 10 min turn over there!
For PS I usually set 8-10/3-4 with a Rate of 8. The sevo goes down, the propofol redistributes, the co2 goes up and they're breathing in a few minutes.
They all get versed pre op unless they ask to hold it.
 
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^^^ this just further shows how in this business there is more than one way to skin a cat.

Another reason I like the deep extubation relates to exactly what IlDestriero elluded too. It's so difficult to start to lighten up the anesthetic while the mouth gag is still in place. Then the surgeon says, we're done and you turn everything off. It never fails as they are about to pull the suspension device they grab the bovie and go back for another round "real quick like." So I usually give a propofol bolus right about this time or a little sooner so that I can still get rid of gas (there's nothing wrong with gas, this is just my preference since I think propofol wake ups are better than gas wake ups) and they don't buck on the suspension. Many years of T&A's and this is the technique I have come up with.

If I don't like the airway with regards to hemostasis then we wait a few minutes for the kid to emerge. But my surgeon and I have a good system that we both understand.

I have seen mild spasms (not sure I can call it laryngospasm) in the pacu in nearly 15 yrs of this but so far never had to intervene. I think my younger parntners have had more of this according to the pacu nurses. I don't know. Haven't seen one in maybe a couple years. I guess I'm due for one.
 
Anyone else do 0.5-1 mcg/kg bolus of precedex right after the tube is out? Keeps them nice and chill in PACU...just be sure to push some glyco with it.

ya don't need the glyco. the HR slows every time but it never needs treatment (so long as the kid doesn't get hypoxic).

if you're going to give precedex, why not give it at the start (when the HR is up anyway) and skip the opiate altogether?
 
CA1 here, great to read the various reasonings for different approaches. I actually read this thread the other day before starting my peds rotation and found it helpful. Though, here we evidently use LMAs unless there is a compelling reason to do otherwise. Otherwise we used 20mcg/kg of dilaudid, some propofol, put the LMA in and then a little propofol prior to pulling it at the end. Seemed to work well with my n=1.
 
ya don't need the glyco. the HR slows every time but it never needs treatment (so long as the kid doesn't get hypoxic).

if you're going to give precedex, why not give it at the start (when the HR is up anyway) and skip the opiate altogether?

Ehh I don't know, I've seen some pretty exaggerated responses to precedex boluses without glyco...like down to the 30s. My go to for T+As is usually 1mcg/kg fent on induction with 2 per of prop, 4-8mg decadron depending on age, tylenol 15mg/kg, morphine 75mcg/kg, and then 0.5-1mcg/kg precedex bolus on wakeup. A million ways to skin a cat as we've all seen in this thread.
 
Ehh I don't know, I've seen some pretty exaggerated responses to precedex boluses without glyco...like down to the 30s. My go to for T+As is usually 1mcg/kg fent on induction with 2 per of prop, 4-8mg decadron depending on age, tylenol 15mg/kg, morphine 75mcg/kg, and then 0.5-1mcg/kg precedex bolus on wakeup. A million ways to skin a cat as we've all seen in this thread.

how are you giving it? at what starting HR?

i've given that dose (0.5-1ug/kg) and more to hundreds of kids; when i started trying it i gave glyco every time out of fear. after reviewing the literature i stopped. i give the 0.5-2ug/kg over the course of the tonsillectomy in divided bolusses - have never seen a HR<60. usually the HR drops by 20 points. BP never suffers.

check out this data:

Paediatr Anaesth. 2008 May;18(5):403-11. doi: 10.1111/j.1460-9592.2008.02468.x. Epub 2008 Mar 18.
High dose dexmedetomidine as the sole sedative for pediatric MRI.
Mason KP1, Zurakowski D, Zgleszewski SE, Robson CD, Carrier M, Hickey PR, Dinardo JA.

pretty high doses - some pretty low HR's - no interventions, no adverse outcomes.

but as you say, lotsa ways to skin kitty. whatever works for ya.
 
I never really understood precedex as the sole anesthetic for MRI. I use an LMA. Works great every time and the kids wake up and get out of my recovery space quickly. I have used it for awake fibers, etc. with other meds. I've also started using it in patients with a history of bad emergence delirium.
 
I never really understood precedex as the sole anesthetic for MRI. I use an LMA. Works great every time and the kids wake up and get out of my recovery space quickly. I have used it for awake fibers, etc. with other meds. I've also started using it in patients with a history of bad emergence delirium.

i like a propofol gtt with oral airway for pediatric mri
 
i like a propofol gtt with oral airway for pediatric mri
I like those propofol gtts as well but if the kid needs and oral airway then I just put an LMA in. Otherwise, I use nasal cannula with CO2 monitoring.
 
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