Smoothing out peds emergence delirium

[Ignatius J]

So really, I'm looking for more calm kiddos, with the following details on my sitch:

1. High volume turnover, so can't chill in the OR waiting for a while for emergence if I want be able to put my kids to bed.

2. No Precedex, a work in progress to try and obtain.

Just interested in hearing what works and what doesn't for others, assuming pain is adequately treated.

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[Intubate]

Clonidine 0.5/kg iv.

 

[kazuma]

I like a small whiff of propofol in the last 10-15 min of the case which usually smooths emergence in kids and teens. I've heard clonidine works well too but I've only used it a few times.

 

[Numbex]

What cases in particular?

 

[Noyac]

Kazuma has the trick. Give them some propofol at the end of the case. Very small dose, like 1-2cc if they are under 30kg or so. You should also make sure their pain is well covered obviously. I like a nice slow resp rate around 16-22. Depending on age.
And finally, the best trick if the case warrants is to pull the tube deep. Put the kiddo on their side, assure sp. resp is adequate and airway is patent. Roll to PACU. Pt emerges on their own terms in quiet environment.

 

[kazuma]

I agree Noyac, pulling the tube/LMA deep is the best trick if it's safe and you have competent PACU nurses. I sometimes use a shoulder roll if I don't roll them on their side. I always bring an appropriate sized mask and oral airway with me to the PACU. The mask can be used as a soft cushion/pillow when placed over their ear/side of face to help prop the head up.

 

[pjl]

There was a recent article with small dose versed IV, they showed delayed discharge time by 2 minutes, but greatly reduced delirium. Maybe I'll find a link later.

 

[Ignatius J]

What cases in particular?

I'm doing a lot of pedi dental and ENT. Probably will have some urology as well eventually.

If it's just a few minor things done, I'll pull it deep on dental stuff. If they have some bleeding and secretions I stay away from that at this point in my career.

If I pull it deep, I make sure and work in narcotic in the preceding ten minutes. Not sure if it's dogma or not, but if narcotics blunt airway reflexes on intubation, I think they can on extubation as well.

Still, although most are fairly smooth, every now and then a kid on one far side of the bell curve wakes up screaming bloody murder.

 

[Ignatius J]

There was a recent article with small dose versed IV, they showed delayed discharge time by 2 minutes, but greatly reduced delirium. Maybe I'll find a link later.

I'm sure many anesthesiologist and PACU personnel will take that trade-off.

 

[Noyac]

Still, although most are fairly smooth, every now and then a kid on one far side of the bell curve wakes up screaming bloody murder.

One every once in a while is not bad at all.

 

[kazuma]

There was a recent article with small dose versed IV, they showed delayed discharge time by 2 minutes, but greatly reduced delirium. Maybe I'll find a link later.

At the stand alone peds hopital the attendings are more liberal with versed and aren't scared to use it at the end of a case and I've heard it works well. All of my peds cases have been at our main campus where it's not used routinely. Delaying discharge by 2 minutes seems like a very small price to pay for greatly reduced delirium.

 

[michigangirl]

Titrate narcotic at the end of the case to get RR low but appropriate for age/maintenance of minute ventilation (not for infants! RR 10 for adolescents, 10-20 for toddlers and older kids) and pull deep when appropriate (no airway issues, no URI, no secretions/blood, as others have mentioned, appropriate PACU staff). If you can't pull deep, getting RR down before turning off gas still helps significantly.

Considering benzos are a major risk factor for ICU delirium, I am skeptical of preemptively treating at the end of a case to PREVENT delirium. I completely advocate for benzo use pre-op as an anxiolytic in the right situation since that is its actual benefit and the risk-benefit ratio may point more toward benefit.

 

[Noyac]

Titrate narcotic at the end of the case to get RR low but appropriate for age/maintenance of minute ventilation (not for infants! RR 10 for adolescents, 10-20 for toddlers and older kids) and pull deep when appropriate (no airway issues, no URI, no secretions/blood, as others have mentioned, appropriate PACU staff). If you can't pull deep, getting RR down before turning off gas still helps significantly.

Considering benzos are a major risk factor for ICU delirium, I am skeptical of preemptively treating at the end of a case to PREVENT delirium. I completely advocate for benzo use pre-op as an anxiolytic in the right situation since that is its actual benefit and the risk-benefit ratio may point more toward benefit.

Agree with most here but a few of my observations are:
- deep extubation is especially important in kiddos with recent URI. I understand the desire to maintain the airway until "awake" I these kids but having one emerge with a tube in place will stimulate bronchospasm more than anything. I even LTA the crap out of these kids if it's a shorter case just to blunt the response even more.
-I personally have not had the same experience with pre-op benzos. I find that these kids are less consolable post-op. They may be more worked up emotionally going into the OR but they go to sleep instandptly, Sevo at 8% in N2O/O2 right away. Monitors latter. Then a splash of prop for emergence. This is my best approach.

 

[michigangirl]

Agree with most here but a few of my observations are:
- deep extubation is especially important in kiddos with recent URI. I understand the desire to maintain the airway until "awake" I these kids but having one emerge with a tube in place will stimulate bronchospasm more than anything. I even LTA the crap out of these kids if it's a shorter case just to blunt the response even more.
-I personally have not had the same experience with pre-op benzos. I find that these kids are less consolable post-op. They may be more worked up emotionally going into the OR but they go to sleep instandptly, Sevo at 8% in N2O/O2 right away. Monitors latter. Then a splash of prop for emergence. This is my best approach.

If the kid has a history of wheezing/asthma, then I agree about URI and deep extubation. If not, the risk of laryngospasm on the way to the PACU after a deep extubation is much higher than the risk of bronchspasm from ETT stimulation when waking up, hands down. Vast majority of kids with URI won't wheeze with an ETT. But all kids love a good laryngospasm if you set 'em up right.

I rarely use benzos pre-op, but there are obvious situations where it helps-- for the little ones (less than 3), if you're giving them benzo you're just treating the parents. 8% and go. But when you take one look at a healthy 7 year old from across the pre-op area and their eyes scream glistening fear, when the nurse asks them to get on a scale for a weight, a little benzo can go a long way. Right situation. The vast majority of kids are better served without benzo period. A little personality, a little humor, a little distraction is all the benzo you need-- most of the time.

 

[deleted9493]

If the kid has a history of wheezing/asthma, then I agree about URI and deep extubation. If not, the risk of laryngospasm on the way to the PACU after a deep extubation is much higher than the risk of bronchspasm from ETT stimulation when waking up, hands down. Vast majority of kids with URI won't wheeze with an ETT. But all kids love a good laryngospasm if you set 'em up right.

I rarely use benzos pre-op, but there are obvious situations where it helps-- for the little ones (less than 3), if you're giving them benzo you're just treating the parents. 8% and go. But when you take one look at a healthy 7 year old from across the pre-op area and their eyes scream glistening fear, when the nurse asks them to get on a scale for a weight, a little benzo can go a long way. Right situation. The vast majority of kids are better served without benzo period. A little personality, a little humor, a little distraction is all the benzo you need-- most of the time.

Not entirely true. Zeev Kain has written extensively on the longer term problems associated with not premedicating--these seem to include higher incidence of bed wetting and learning problems in the ensuing months. I meet kids all the time who had traumatic experiences in the past, having been held down for mask inductions without a premed and are freaked out by the idea of surgery as a result.

The postop delirium concern with midazolam premedication is overstated and only weakly linked. Fast emergence from sevoflurane and desflurane is probably the greatest risk factor.

Midazolam is great as a post-med. Clonidine is also great but will result in a sedative effect for up to 24hrs--not necessarily ideal for outpatient surgery. Deep extubation on propofol with analgesia well-covered is my go to. If a child has a history of emerging wild, I'll add midazolam into the mix. I can't remember the last time I saw emergence delirium...and I always ask how my patients recover. Oh, and I do use dexmedetomidine on tonsil days when there are several kids I know will benefit from it.

 

[michigangirl]

Zeev Kain's co-authored a nice pro-con on the subject: http://www.ncbi.nlm.nih.gov/pubmed/19691689-- nice perspectives from both sides.

One of the keys mentioned here (and well written in the abstract) is you can't attribute being freaked out by the surgery as being solely related to mask inductions-- a hospitalization is a multifaceted process that brings with it many stressors that play a role in future surgeries/hospitalizations.

I cringe at the anesthesiologist that makes no effort to smooth out the induction using interactive techniques-- hold em down and go should never be the default in a child with whom you can communicate in a meaningful way. We can go back and forth about the effects of not having premed, but I think too many people sub premed for good ol' fashioned personal interaction with the kid or other clever induction techniques. It may take a little extra time, but that it can go a long way. We can also go back and forth about the potential effects of benzodiazepine on the developing brain during a critical phase of synaptic pruning. Bottom line, so many confounders, so many ways to skin the cat. Everyone wants the kid to go to sleep happily and wake up smoothly. The research is not definitive...yet. We all practice in a way that has worked for us personally to achieve that goal. That's why this board rocks-- lots of perspectives and approaches for trainees to think about!

 

[Noyac]

If the kid has a history of wheezing/asthma, then I agree about URI and deep extubation. If not, the risk of laryngospasm on the way to the PACU after a deep extubation is much higher than the risk of bronchspasm from ETT stimulation when waking up, hands down. Vast majority of kids with URI won't wheeze with an ETT. But all kids love a good laryngospasm if you set 'em up right.

Ok, if I understand your point correctly, you are saying kids with no history of asthma/wheezing have a lower risk of bronchospasm than laryngospasm. That part I agree with.
As far as your other point regarding laryngospasm on the way to PACU, I have no numbers to argue this point with you. But I have "never" seen in my cases or my partners cases, a kid laryngospasm on the way to the pacu after extubation. I know it can and has happened but it isn't that common. A well orchestrated deep or awake extubation should protect the pt from this. And to call it a "much" higher risk, I guess, is a personal call. I don't think there are any studies to prove my point, much less yours. Please consider your comments. Are they from experience or are they from dogma left over from your training? I realize that that seems like an attack. I assure you, it is not! But we are taught a lot of things, and rightfully so, that are not necessarily true.
Now with all that being said. We, as a group, had two cases last year that followed your logic (no h/o asthma wheezing and a recent URI so extubated wide awake) and ended up in the PICU. Now, technique still comes into play and my 2 case study obviously means nothing in the big scheme of things. But, I'll continue with my approach due to these cases and my personal history of dealing with kids with recent URIs.

 

[somedumbDO]

Coming from one of the few big private peds high volume practices left aka (non academic) wanted to chime in a little here. Deep extubations are the key to decreased post op delirium. I agree with Noyac I deep extubate 99% of all my kids, except full stomachs, and cleft palate/jaw adv surgeries for treacher collins ect kids. I have NEVER seen a kid larygospasm on the way to pacu, breathing well, rescue position and we are off. By the time my paper work is filled out and I chat with the parents the kid is out of stage2 and I leave. I would dare say the second "cause" (not a true delirium but hard to differentiate sometime) is poorly treated pain postoperatively. Titrating to the RR of the AP seems prudent on procedures that are painful. Dental rehab with nerve blocks. Ortho/urology/gensurg with nerve blocks and/or caudals IMHO do not need narcs and only delay pacu d/c. I view each patient as a case by case scenario. If the kid and parents have a high anxiety component preoperatively guess what your gonna have a hellian after. Clonidine/precedex are my goto meds in this situation. As long as pain is adequately treated. I have used propofol in the past it works but sometimes kids will need another "hit" in pacu and I am already inducing the next kid in the OR, I don't want to be troubled with that. As far as premed in the private practice setting ALL kids get it. Once this kid is induced I am calling preop to find out info and getting the kid preopped/premeded for the next case. I cant waste 20 min for midaz to kick in and hold up the OR (25% of our procedures takes less than 20min to complete!) In academics I am sure you can. Besides MOST Kids age 2-4 NEED it. No amount of distraction/play/diversion is gonna make them better. There is a reason they call it the terrible twos. Also, most parents are crazy in this day and age and these people are NOT coming back to the or with the kid. Post surgical cognitive dysfuction and sleep disturbance is real entity. Problem is we also have a time restraint. Productivity matters! All you can do is make induction as QUICKLY and CALM as possible.

 

[michigangirl]

Ok, if I understand your point correctly, you are saying kids with no history of asthma/wheezing have a lower risk of bronchospasm than laryngospasm. That part I agree with.
As far as your other point regarding laryngospasm on the way to PACU, I have no numbers to argue this point with you. But I have "never" seen in my cases or my partners cases, a kid laryngospasm on the way to the pacu after extubation. I know it can and has happened but it isn't that common. A well orchestrated deep or awake extubation should protect the pt from this. And to call it a "much" higher risk, I guess, is a personal call. I don't think there are any studies to prove my point, much less yours. Please consider your comments. Are they from experience or are they from dogma left over from your training? I realize that that seems like an attack. I assure you, it is not! But we are taught a lot of things, and rightfully so, that are not necessarily true.
Now with all that being said. We, as a group, had two cases last year that followed your logic (no h/o asthma wheezing and a recent URI so extubated wide awake) and ended up in the PICU. Now, technique still comes into play and my 2 case study obviously means nothing in the big scheme of things. But, I'll continue with my approach due to these cases and my personal history of dealing with kids with recent URIs.

Agree! No attack perceived. Per my previous post-- all based on experience, not dogma or literature. I also couch this with the context of my other hat as an intensivist taking care of status asthmaticus in the PICU, as Noyac said we get a few admissions each year of severe peri-extubation bronchospasm who come to the PICU intubated-- usually a kid who wheezed sometime back in the day, had a URI blooming which blossomed all out under anesthesia, but the wheezing history was minimized. With experience comes ability to delineate risk, level of index of suspicion.

The interesting risk/benefit discussions are the kids who are a mixed bag for deep vs. awake. Take the 3 year old Difficult Airway Fontan s/p Cath with severe persistent asthma who wheezed on induction-- good times! Or replace fontan with pulmonary hypertension. or both! Discuss! Pros/cons for awake vs. deep extubation?

 

[deleted9493]

Agree! No attack perceived. Per my previous post-- all based on experience, not dogma or literature. I also couch this with the context of my other hat as an intensivist taking care of status asthmaticus in the PICU, as Noyac said we get a few admissions each year of severe peri-extubation bronchospasm who come to the PICU intubated-- usually a kid who wheezed sometime back in the day, had a URI blooming which blossomed all out under anesthesia, but the wheezing history was minimized. With experience comes ability to delineate risk, level of index of suspicion.

The interesting risk/benefit discussions are the kids who are a mixed bag for deep vs. awake. Take the 3 year old Difficult Airway Fontan s/p Cath with severe persistent asthma who wheezed on induction-- good times! Or replace fontan with pulmonary hypertension. or both! Discuss! Pros/cons for awake vs. deep extubation?

In your example, "it depends" on why they were difficult (edema vs. anatomy vs. poor conditions) and just how difficult. If I am confident of my ability to mask ventilate them and re-intubate them with my scope of choice: low dose glycopyrrolate during the case to clear secretions and for bronchodilation, opioid titrated to a spontaneous respiratory rate with ETCO2 in the low 40's (at 1 MAC), 10mcg/mL epinephrine at the ready. Extubate deep and help the kiddo breath at FRC with gentle PPV and oral airway (if volumes any less than ideal without it). Kids laryngospasm all the time on oral airways and so I only use them if necessary. Emerge on the table before going anywhere.

Pros: extubating deep removes the greatest risk factor for pulmonary hypertension and bronchospasm--the tube.

Cons: removing the tube also removes your greatest assurance that you will be able to oxygenate/ventilate adequately

In scenarios like this, good judgement--knowing when it's the best option to be conservative and when it's not--is paramount. Also, this is a scenario that requires a high level of vigilance and decisiveness to act immediately when you're not completely satisfied. The margins are much smaller here.

 

[IlDestriero]

I'm not sure that I agree that kids laryngospasm on oral airways all the time, or even very often. I use them all the time and nobody is overheading me to the PACU for laryngospasm. If they obstruct significantly going to sleep they get one to wake up (or a nasal airway) if I extubate them deep. I also take many kids to the PACU asleep and they emerge there on their own schedule long after I've gone on to the next.
That may not work for your PACU staff, so adjust accordingly.

 

[michigangirl]

In your example, "it depends" on why they were difficult (edema vs. anatomy vs. poor conditions) and just how difficult. If I am confident of my ability to mask ventilate them and re-intubate them with my scope of choice: low dose glycopyrrolate during the case to clear secretions and for bronchodilation, opioid titrated to a spontaneous respiratory rate with ETCO2 in the low 40's (at 1 MAC), 10mcg/mL epinephrine at the ready. Extubate deep and help the kiddo breath at FRC with gentle PPV and oral airway (if volumes any less than ideal without it). Kids laryngospasm all the time on oral airways and so I only use them if necessary. Emerge on the table before going anywhere.

Pros: extubating deep removes the greatest risk factor for pulmonary hypertension and bronchospasm--the tube.

Cons: removing the tube also removes your greatest assurance that you will be able to oxygenate/ventilate adequately

In scenarios like this, good judgement--knowing when it's the best option to be conservative and when it's not--is paramount. Also, this is a scenario that requires a high level of vigilance and decisiveness to act immediately when you're not completely satisfied. The margins are much smaller here.

So Hudsontc made this easy for the trainees on the board-- let's say the intubation took a few years off your life and you decide to wake the kid up-- wheezing ensues. Now what? What are the physiologic factors at play that may take you toward an arrest? What are the problems with the treatment options?

On another note, I do agree with IlDestriero-- I have never had a kid laryngospasm with an oral airway in place IF the tube was truly taken out deep. If they are anywhere close to stage 2 when the ETT comes out and someone stuffs an oral airway in there, very high chance the kid will let you know. I love oral airways for deep extubations in those kids who obstructed with induction. They just take em out themselves or the nurses do when they're ready. As mentioned, PACU team needs to be on board.

 

[sevoflurane]

Deep extubation. Only 5+ years doing it this way.... but wouldn't do it any other way. Zero complications. Zero.
IMHO, the key to consistent and successful delivery of your pedi patients to the pacu handoff is breathing patterns before you leave the OR. You need to pull your eyes off the monitors and really focus on the child and understand what is normal and what is not... plus execute a peaceful extubation. Additionally, I have a mental checklist before I leave the OR. It has kept me out of trouble.

Getting mom in the room early is very helpful as a lot of the crying is not pain but instead a room full of strangers telling the 4mo.-8 y/o what to do. Little ones don't like stranger anxiety.

 

[IlDestriero]

And don't forget to slam a bottle of juice in their mouths.
They like-a tha juice.

 

[deleted9493]

So what you all are saying, is that a piece of plastic on the larynx during emergence is not a causal factor in laryngospasm? I ask, only because I have had a string of patients (of late) coming to the PACU who were extubated truly deep (as far as I can tell) have oral airway in and have all the signs of laryngospasm (visible tracheal collapse and obstruction with strong respiratory effort) which breaks with PPV. I am inclined to believe these to be laryngospasm because their airways were previously patent on rolling to PACU. Amazing what you learn acting as a 'float' covering for perioperative issues.

Today's event was a repaired TEF toddler who had a dilation. Laryngospasm after about 5 minutes in the PACU with an OA in. Broke with CPAP--breath sounds clear as yours and mine.

Michigangirl, my pharmacologic plan would be the same for an awake extubation, with the addition of 2 mL of 2% lidocaine down the ETT while still deep, retraction of the cuff to the cords (also while deep), and small boluses (5mcg) of empiric IV epinephrine to improve bronchodilation. Now, in Fontan circulation, the systemic ventricle drives flow...both arterial and venous. Any increase in PVR induced by the epinephrine will be overcomed by increased cardiac output and improved aeration.

 

[Noyac]

It seems as though we are all on the same page.

 

[IlDestriero]

We don't have a pacu float, and I may be the only one at the ASC, so I'd hear about any PACU problems. So, yes, a properly sized OP airway doesn't, in my experience, induce laryngospasm in children. The PACU nurses aren't breaking any laryngospasm with PPV on their own either, that's for sure!
And as you probably know, I don't exactly take care of the healthiest of kids.